Healthcare Provider Details

I. General information

NPI: 1780842633
Provider Name (Legal Business Name): JEFFREY ELLIOTT CRYDER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 MASON PHILIP DRIVE
MACON GA
31216-7366
US

IV. Provider business mailing address

179 MASON PHILIP DR
MACON GA
31216-7366
US

V. Phone/Fax

Practice location:
  • Phone: 706-319-7470
  • Fax:
Mailing address:
  • Phone: 706-319-7470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN166777
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: