Healthcare Provider Details

I. General information

NPI: 1700021623
Provider Name (Legal Business Name): JASON BRIAN GRAVES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10509 PENMARRIC COURT
CHARLOTTE NC
28270
US

IV. Provider business mailing address

PO BOX 689022
FRANKLIN TN
37068-9022
US

V. Phone/Fax

Practice location:
  • Phone: 228-224-6523
  • Fax:
Mailing address:
  • Phone: 615-778-8079
  • Fax: 615-778-8079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-118848
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR887060
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: