Provider Demographics
NPI:1780022871
Name:PAUL, JACOB R (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:PAUL
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 1:4025 N 92ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1613
Mailing Address - Country:US
Mailing Address - Phone:414-358-5431
Mailing Address - Fax:
Practice Address - Street 1:200 FOX GLEN CT
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-1809
Practice Address - Country:US
Practice Address - Phone:847-382-7165
Practice Address - Fax:847-713-8160
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163723367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered