Provider Demographics
NPI:1063742716
Name:GELDRICH, JACOB MATTHEW (CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MATTHEW
Last Name:GELDRICH
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 1:2127 ACADEMY WAY
Mailing Address - Street 2:
Mailing Address - City:LAVERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-0000
Mailing Address - Country:US
Mailing Address - Phone:865-680-6061
Mailing Address - Fax:
Practice Address - Street 1:2127 ACADEMY WAY
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-3821
Practice Address - Country:US
Practice Address - Phone:865-680-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-31
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000014614367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered