=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811081649
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN D LAVERTY CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1025 NEW MOODY LN
-----------------------------------------------------
City | LAGRANGE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40031-9154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-222-3886
-----------------------------------------------------
Fax | 502-222-8647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 HARDIN HOLLY
-----------------------------------------------------
City | LAGRANGE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40031-8985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-222-1170
-----------------------------------------------------
Fax | 502-222-8647
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 1089893
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------