Healthcare Provider Details

I. General information

NPI: 1609016187
Provider Name (Legal Business Name): JUSTIN MICHAEL DAVIDSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2594 NORTHERN OAK DR
BRASELTON GA
30517-6058
US

IV. Provider business mailing address

2594 NORTHERN OAK DR
BRASELTON GA
30517-6058
US

V. Phone/Fax

Practice location:
  • Phone: 404-731-9686
  • Fax: 478-352-0095
Mailing address:
  • Phone: 404-731-9686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN170478
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: