Provider Demographics
NPI:1598043572
Name:HANTLA, JACOB D (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:D
Last Name:HANTLA
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 1:1849 W ORCHID LN
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-9034
Mailing Address - Country:US
Mailing Address - Phone:480-241-3769
Mailing Address - Fax:480-393-4109
Practice Address - Street 1:1849 W ORCHID LN
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-9034
Practice Address - Country:US
Practice Address - Phone:480-241-3769
Practice Address - Fax:480-393-4109
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN139385163W00000X
FLRN9307995163W00000X
AZCRNA0786367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse