Provider Demographics
NPI:1457767089
Name:NIBARGER, JACOB (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:NIBARGER
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 1:6400 BELL ST
Mailing Address - Street 2:APARTMENT 6101
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-6638
Mailing Address - Country:US
Mailing Address - Phone:817-917-2465
Mailing Address - Fax:
Practice Address - Street 1:1600 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1799
Practice Address - Country:US
Practice Address - Phone:817-917-2465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXAP126573367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program