Healthcare Provider Details

I. General information

NPI: 1215340732
Provider Name (Legal Business Name): JASON FORTUNA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N CEDAR BLUFF RD STE 300
KNOXVILLE TN
37923-3623
US

IV. Provider business mailing address

410 N CEDAR BLUFF RD STE 300
KNOXVILLE TN
37923-3623
US

V. Phone/Fax

Practice location:
  • Phone: 865-342-8900
  • Fax: 865-691-0843
Mailing address:
  • Phone: 865-342-8900
  • Fax: 865-691-0843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28238845A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number21390
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: