Healthcare Provider Details

I. General information

NPI: 1265012702
Provider Name (Legal Business Name): JON-DAVID NICHOLAS PRICE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5545 MURRAY AVE STE 130
MEMPHIS TN
38119-3861
US

IV. Provider business mailing address

5545 MURRAY AVE STE 130
MEMPHIS TN
38119-3861
US

V. Phone/Fax

Practice location:
  • Phone: 901-682-6828
  • Fax:
Mailing address:
  • Phone: 901-682-6828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number29883
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: