Provider Demographics
NPI:1801857818
Name:MARCHESSEAULT, JEAN EDWARD JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEAN
Middle Name:EDWARD
Last Name:MARCHESSEAULT
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:600 W HUBBARD ST APT 41
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2271
Mailing Address - Country:US
Mailing Address - Phone:208-669-3830
Mailing Address - Fax:
Practice Address - Street 1:12606 E MISSION AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3421
Practice Address - Country:US
Practice Address - Phone:509-473-5723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACRNA1654367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN403089Medicaid
CARN403089Medicaid