Healthcare Provider Details

I. General information

NPI: 1558492157
Provider Name (Legal Business Name): JOE ALVIN SANDERS C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BLUEBIRD BLVD
FORT VALLEY GA
31030-5082
US

IV. Provider business mailing address

4581 THIRD DISTRICT RD
UNADILLA GA
31091-4139
US

V. Phone/Fax

Practice location:
  • Phone: 478-825-8691
  • Fax: 478-825-4458
Mailing address:
  • Phone: 229-645-3495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN113320
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: