Provider Demographics
NPI:1750053351
Name:BOLL, JACOB (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BOLL
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 1:555 SW 7TH ST UNIT 7
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-4532
Mailing Address - Country:US
Mailing Address - Phone:716-307-6088
Mailing Address - Fax:
Practice Address - Street 1:1316 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:IA
Practice Address - Zip Code:50525-2019
Practice Address - Country:US
Practice Address - Phone:515-532-8211
Practice Address - Fax:515-532-3119
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY712697363A00000X, 367500000X
IAD168676367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant