Provider Demographics
NPI:1831648989
Name:BECK, JONATHAN MICHAEL (DNP, CRNA)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:BECK
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 RAY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1059
Mailing Address - Country:US
Mailing Address - Phone:612-300-8669
Mailing Address - Fax:
Practice Address - Street 1:611 SHERMAN AVE E
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1960
Practice Address - Country:US
Practice Address - Phone:920-568-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI514408367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered