Healthcare Provider Details

I. General information

NPI: 1992181382
Provider Name (Legal Business Name): CLINTON H. BRAKEBILL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3651 WHEELER RD
AUGUSTA GA
30909-6521
US

IV. Provider business mailing address

PO BOX 204097
AUGUSTA GA
30917-4097
US

V. Phone/Fax

Practice location:
  • Phone: 706-651-3232
  • Fax: 706-650-1034
Mailing address:
  • Phone: 706-466-4541
  • Fax: 706-650-1034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN181883
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: