Provider Demographics
NPI:1104841105
Name:SNOWDEN, JUSTIN (CRNA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SNOWDEN
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 1:925 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2203
Mailing Address - Country:US
Mailing Address - Phone:318-323-8887
Mailing Address - Fax:847-615-2858
Practice Address - Street 1:503 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5327
Practice Address - Country:US
Practice Address - Phone:318-323-8887
Practice Address - Fax:847-615-2858
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03916367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1109789Medicaid
LA1109789Medicaid
LA4B918CY90Medicare PIN