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General NPI Number Information
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NPI Number | 1306945944
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Entity Type | Individual
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Provider Name | JERRY L MIXON CRNA
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Gender | Male
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 03/02/2009
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Provider Practice Location Address
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Address Line | 4920 NE STALLINGS DR
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City | NACOGDOCHES
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State | TX
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Zip | 75965-1254
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Country | US
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Telephone | 936-569-9481
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Fax | 936-462-4333
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Provider Business Mailing Address
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Address Line | PO BOX 632114
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City | NACOGDOCHES
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State | TX
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Zip | 75963-2114
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Country | US
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Telephone | 936-568-0087
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 227393
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License Number State | TX
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