Provider Demographics
NPI:1356432785
Name:NETHERLAND, JAN LEWIS (CRNA)
Entity type:Individual
Prefix:MR
First Name:JAN
Middle Name:LEWIS
Last Name:NETHERLAND
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 1:4045 KRISTANNA DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3291
Mailing Address - Country:US
Mailing Address - Phone:850-271-8333
Mailing Address - Fax:
Practice Address - Street 1:4045 KRISTANNA DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3291
Practice Address - Country:US
Practice Address - Phone:850-271-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1450052367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered