Provider Demographics
NPI:1114960143
Name:BURKS, JONATHAN WAYNE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:WAYNE
Last Name:BURKS
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 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2061
Mailing Address - Fax:615-296-9949
Practice Address - Street 1:3024 BUSINESS PARK CIR
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-3132
Practice Address - Country:US
Practice Address - Phone:615-239-2061
Practice Address - Fax:615-296-9949
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN10090367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36262671Medicaid
TN36262671Medicare PIN