Provider Demographics
NPI:1457741167
Name:LUFKIN, JACOB L (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:L
Last Name:LUFKIN
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 1:123 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1529
Mailing Address - Country:US
Mailing Address - Phone:208-604-5009
Mailing Address - Fax:
Practice Address - Street 1:164 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1597
Practice Address - Country:US
Practice Address - Phone:208-847-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28219682A163W00000X
ID57248367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse