Healthcare Provider Details

I. General information

NPI: 1952335572
Provider Name (Legal Business Name): JERRY RYAN WELBORN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/15/2024
Certification Date: 09/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8375 HIGHWAY 72 W
MADISON AL
35758-9573
US

IV. Provider business mailing address

PO BOX 2045
MERIDIAN MS
39302-2045
US

V. Phone/Fax

Practice location:
  • Phone: 205-265-2012
  • Fax:
Mailing address:
  • Phone: 662-380-3513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR862001
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-134799
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: