Provider Demographics
NPI:1073086310
Name:ELISON, CASEY JORDAN (CRNA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:JORDAN
Last Name:ELISON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:2823 FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721
Practice Address - Country:US
Practice Address - Phone:559-459-6000
Practice Address - Fax:559-498-8182
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA95001060367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID41321OtherBOARD OF REGISTERED NURSING
CA95109684OtherBOARD OF REGISTERED NURSING
CANA950001060OtherBOARD OF REGISTERED NURSING