Healthcare Provider Details

I. General information

NPI: 1780670729
Provider Name (Legal Business Name): THOMAS GUY FEVURLY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE 673D MDG / SGCS / SGCJ
JBER AK
99506-3702
US

IV. Provider business mailing address

66 ALPINE AVE
JBER AK
99505-1021
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-1815
  • Fax: 907-580-5524
Mailing address:
  • Phone: 937-789-7488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN 313609 / NA-07927
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number118337
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: