Provider Demographics
NPI:1649400755
Name:RICHARD, JACOB IRION (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:IRION
Last Name:RICHARD
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 1:131 CINCLARE DR
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-8083
Mailing Address - Country:US
Mailing Address - Phone:985-447-4102
Mailing Address - Fax:
Practice Address - Street 1:1978 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-7055
Practice Address - Country:US
Practice Address - Phone:985-873-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05864367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered