Provider Demographics
NPI:1578520136
Name:IRONSIDE, JAY P (CRNA)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:P
Last Name:IRONSIDE
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:W14145 CREST VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-9559
Mailing Address - Country:US
Mailing Address - Phone:608-370-6282
Mailing Address - Fax:
Practice Address - Street 1:80 1ST ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1550
Practice Address - Country:US
Practice Address - Phone:608-643-7299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI147652367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43331500Medicaid
WI43331500Medicaid