Provider Demographics
NPI:1578721544
Name:CROSBY, JACOB L (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:L
Last Name:CROSBY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:L
Other - Last Name:CROSBY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 94289, MS 631130
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0618
Mailing Address - Country:US
Mailing Address - Phone:866-487-0277
Mailing Address - Fax:770-701-6676
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:866-487-0277
Practice Address - Fax:770-701-6674
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-103663-111163W00000X
UT501146-3102163W00000X
KS55640367500000X
WY268930997367500000X
ID62128367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse