Provider Demographics
NPI:1578070793
Name:KANE, JEDIDIAH (CRNA)
Entity Type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:
Last Name:KANE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 GREEN GROVE RD
Mailing Address - Street 2:
Mailing Address - City:SPRING MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:16875-7701
Mailing Address - Country:US
Mailing Address - Phone:801-477-5334
Mailing Address - Fax:
Practice Address - Street 1:3401 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6332
Practice Address - Country:US
Practice Address - Phone:158-035-5862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS43-557962-051367500000X
OK201889367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered