Provider Demographics
NPI:1881754422
Name:LAZERUS, JERRY WAYNE
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WAYNE
Last Name:LAZERUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:LAZERUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:13291 HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-7431
Mailing Address - Country:US
Mailing Address - Phone:501-467-8061
Mailing Address - Fax:
Practice Address - Street 1:13291 HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-7431
Practice Address - Country:US
Practice Address - Phone:501-467-8061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR28178163W00000X
ARC00450367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR59635Medicare ID - Type UnspecifiedMEDICARE