Healthcare Provider Details

I. General information

NPI: 1306105390
Provider Name (Legal Business Name): DUSTIN CONNELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 05/18/2017
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

276 BELFLOWER RD
TIFTON GA
31794-1607
US

V. Phone/Fax

Practice location:
  • Phone: 229-353-6124
  • Fax: 229-353-7722
Mailing address:
  • Phone: 229-392-8840
  • Fax: 478-333-6117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN167296
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: