Healthcare Provider Details

I. General information

NPI: 1891434627
Provider Name (Legal Business Name): AUSTIN LANE TERRELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

3801 ROSEDALE DR
MEMPHIS TN
38111-6918
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-7100
  • Fax:
Mailing address:
  • Phone: 601-551-9085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number905767
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number31867
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: