Provider Demographics
NPI:1639154685
Name:STORMER, JEFFREY (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:STORMER
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 1:1 MEDICAL VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3403
Mailing Address - Country:US
Mailing Address - Phone:859-301-2000
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:20 MEDICAL VILLAGE DR
Practice Address - Street 2:STE 258
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5401
Practice Address - Country:US
Practice Address - Phone:859-341-2666
Practice Address - Fax:859-341-7867
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1028649163W00000X
KY023081367500000X
OH154045163W00000X
OHNA00804367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000537064OtherANTHEM
IN200877890Medicaid
KY74001116Medicaid
9130423OtherPHCS
OH2076159Medicaid
P00422567Medicare PIN
IN200877890Medicaid
9130423OtherPHCS
0918130Medicare PIN