Healthcare Provider Details

I. General information

NPI: 1982885745
Provider Name (Legal Business Name): ANTHONY JASON DEAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MORRIS ST
CHARLESTON WV
25301-1326
US

IV. Provider business mailing address

501 MORRIS ST
CHARLESTON WV
25301-1326
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-6220
  • Fax:
Mailing address:
  • Phone: 304-388-6220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number077845
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: