Healthcare Provider Details

I. General information

NPI: 1306945944
Provider Name (Legal Business Name): JERRY L MIXON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 NE STALLINGS DR
NACOGDOCHES TX
75965-1254
US

IV. Provider business mailing address

PO BOX 632114
NACOGDOCHES TX
75963-2114
US

V. Phone/Fax

Practice location:
  • Phone: 936-569-9481
  • Fax: 936-462-4333
Mailing address:
  • Phone: 936-568-0087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number227393
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: