Healthcare Provider Details

I. General information

NPI: 1982609426
Provider Name (Legal Business Name): ROBERT THORNTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date: 06/27/2005
Reactivation Date: 07/01/2005

III. Provider practice location address

222 PERRY HWY
HAWKINSVILLE GA
31036-6748
US

IV. Provider business mailing address

222 PERRY HWY
HAWKINSVILLE GA
31036-6748
US

V. Phone/Fax

Practice location:
  • Phone: 478-783-0200
  • Fax: 478-783-0802
Mailing address:
  • Phone: 478-783-0200
  • Fax: 478-783-0802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN127449
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: