Healthcare Provider Details

I. General information

NPI: 1083142673
Provider Name (Legal Business Name): COLBY JON WILLIAMSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2017
Last Update Date: 05/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 DIXIE ST
CARROLLTON GA
30117-3818
US

IV. Provider business mailing address

4130 REDWING CIR
BIRMINGHAM AL
35243-3028
US

V. Phone/Fax

Practice location:
  • Phone: 770-836-9666
  • Fax:
Mailing address:
  • Phone: 205-639-8333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN261269
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: