Provider Demographics
NPI:1447300736
Name:JOST, MARLEN BOB (CRNA)
Entity type:Individual
Prefix:
First Name:MARLEN
Middle Name:BOB
Last Name:JOST
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 1:536 45TH ST S APT 208
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-0904
Mailing Address - Country:US
Mailing Address - Phone:701-238-4922
Mailing Address - Fax:
Practice Address - Street 1:900 PEELER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-2380
Practice Address - Country:US
Practice Address - Phone:269-345-8618
Practice Address - Fax:269-345-1508
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704256530367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4975386Medicaid
MA4975386Medicaid