Provider Demographics
NPI:1578668273
Name:MAST, JESSICA M (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:MAST
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DRIVE
Practice Address - Street 2:1H247 UNVERSITY HOSPITAL
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-4280
Practice Address - Country:US
Practice Address - Phone:734-936-4280
Practice Address - Fax:248-849-5489
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225322367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4830020Medicaid
MI0N21370235Medicare ID - Type Unspecified
MI4830020Medicaid