Provider Demographics
NPI:1801209200
Name:STAHL, JACOB (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:STAHL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4100 PARK FOREST DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7331
Mailing Address - Country:US
Mailing Address - Phone:231-935-5770
Mailing Address - Fax:231-935-0747
Practice Address - Street 1:4100 PARK FOREST DR
Practice Address - Street 2:SUITE 201
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7331
Practice Address - Country:US
Practice Address - Phone:231-935-5770
Practice Address - Fax:231-935-0747
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272613367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801209200Medicaid
MI1801209200Medicaid