Provider Demographics
NPI:1659376457
Name:JONES, MARVIN LEE (MSN, CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:LEE
Last Name:JONES
Suffix:
Gender:M
Credentials:MSN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1390 BILL VIRDON BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-3383
Mailing Address - Country:US
Mailing Address - Phone:417-256-2225
Mailing Address - Fax:417-256-2373
Practice Address - Street 1:1390 BILL VIRDON BLVD
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-3383
Practice Address - Country:US
Practice Address - Phone:417-256-2225
Practice Address - Fax:417-256-2373
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000157074367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO915032015Medicaid
MO824684510Medicare PIN
MO915032015Medicaid
MO000014511Medicare PIN
MO824684511Medicare PIN