Healthcare Provider Details

I. General information

NPI: 1134458896
Provider Name (Legal Business Name): JUSTIN B DEFLUITER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 20TH STREET SUITE 606
KNOXVILLE TN
37916-1863
US

IV. Provider business mailing address

501 20TH STREET SUITE 606
KNOXVILLE TN
37916-1863
US

V. Phone/Fax

Practice location:
  • Phone: 865-546-8040
  • Fax: 865-541-2787
Mailing address:
  • Phone: 865-546-8040
  • Fax: 865-541-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number14469
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: