Healthcare Provider Details

I. General information

NPI: 1801832506
Provider Name (Legal Business Name): JON BOYD POULSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW ST
MARIETTA OH
45750-1635
US

IV. Provider business mailing address

101 RIVERSIDE LN
MARIETTA OH
45750-1448
US

V. Phone/Fax

Practice location:
  • Phone: 740-568-5427
  • Fax:
Mailing address:
  • Phone: 740-336-9201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number56808
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN233430
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.06711
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: