Provider Demographics
NPI:1154315612
Name:BAX, TERRY L (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:BAX
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 1:421 SE ALFRED MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-2204
Mailing Address - Country:US
Mailing Address - Phone:386-697-1364
Mailing Address - Fax:888-370-3379
Practice Address - Street 1:421 SE ALFRED MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-2204
Practice Address - Country:US
Practice Address - Phone:386-697-1364
Practice Address - Fax:888-370-3379
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3002322367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL301528900Medicaid
FLG1977OtherBLUE SHIELD PROV #
FLG1977YMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER
FL301528900Medicaid