Healthcare Provider Details

I. General information

NPI: 1003198268
Provider Name (Legal Business Name): COLE BURGESS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 18TH ST E
TIFTON GA
31794-3648
US

IV. Provider business mailing address

901 18TH ST E
TIFTON GA
31794-3648
US

V. Phone/Fax

Practice location:
  • Phone: 229-353-6124
  • Fax: 229-353-7722
Mailing address:
  • Phone: 229-353-6124
  • Fax: 229-353-7722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN192175
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: