Healthcare Provider Details

I. General information

NPI: 1548256084
Provider Name (Legal Business Name): SUSANNE RAISOR CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 11/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1266 HIGHWAY 515 S
JASPER GA
30143-4872
US

IV. Provider business mailing address

744 NOAH DR SUITE 113-315
JASPER GA
30143-8705
US

V. Phone/Fax

Practice location:
  • Phone: 706-692-2441
  • Fax:
Mailing address:
  • Phone: 706-301-1098
  • Fax: 706-301-9151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN052516
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: