Provider Demographics
NPI:1063480457
Name:SUDDETH, BRENT H (CRNA)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:H
Last Name:SUDDETH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 465686
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30042-5686
Mailing Address - Country:US
Mailing Address - Phone:770-237-1561
Mailing Address - Fax:770-237-1124
Practice Address - Street 1:201 HOSPITAL RD
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2408
Practice Address - Country:US
Practice Address - Phone:404-851-6500
Practice Address - Fax:770-237-1124
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN149420367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN149420OtherGA NURSING LICENSE