Provider Demographics
NPI:1669471827
Name:BIESENTHAL, JAY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:
Last Name:BIESENTHAL
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 1:401 CHARLESTON DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-3950
Mailing Address - Country:US
Mailing Address - Phone:919-553-4527
Mailing Address - Fax:919-553-4527
Practice Address - Street 1:1638 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-609-6440
Practice Address - Fax:910-609-5365
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC127107367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052067Medicaid
NC8052067Medicaid