Provider Demographics
NPI:1174633002
Name:BREWER, JAY R (CRNA)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:R
Last Name:BREWER
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 54
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52537-0054
Mailing Address - Country:US
Mailing Address - Phone:641-664-3602
Mailing Address - Fax:641-664-3765
Practice Address - Street 1:105 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:IA
Practice Address - Zip Code:52537-1458
Practice Address - Country:US
Practice Address - Phone:641-664-3602
Practice Address - Fax:641-664-3765
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD099449367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
430059427OtherRAILROAD MEDICARE
IA0206177Medicaid
IA16605OtherBCBS
16605Medicare ID - Type Unspecified