Provider Demographics
NPI:1326135310
Name:ALLISON, EDWARD J (C R N A)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:J
Last Name:ALLISON
Suffix:
Gender:M
Credentials:C R N A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 E 125TH ROAD
Mailing Address - Street 2:
Mailing Address - City:KANSAS
Mailing Address - State:IL
Mailing Address - Zip Code:61933
Mailing Address - Country:US
Mailing Address - Phone:941-747-2830
Mailing Address - Fax:941-747-6170
Practice Address - Street 1:227 E MCCALLISTER DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4248
Practice Address - Country:US
Practice Address - Phone:765-832-7372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28104495A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN351912401050Medicaid
IN200116030Medicaid
INR40117Medicare UPIN
IN200116030Medicaid