Provider Demographics
NPI:1831182872
Name:MARTIN, JERRY (CRNA)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MARTIN
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:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-2568
Practice Address - Fax:573-882-2226
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN307552174400000X
MO070444367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000325469OtherANTHEM BCBS
OH2442771Medicaid
MO912787918Medicaid
OHMA8232521Medicare ID - Type Unspecified
MO000060540Medicare PIN
OH2442771Medicaid
MO825545236Medicare PIN
MO430075993Medicare PIN