Provider Demographics
NPI:1346230851
Name:KERVIN, MATTHEW WILLIAM (CRNA)
Entity Type:Individual
Prefix:PROF
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:KERVIN
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 1:563 SILVER SHOALS RD
Mailing Address - Street 2:SILVER SHOALS ROAD
Mailing Address - City:EASTANOLLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30538-3523
Mailing Address - Country:US
Mailing Address - Phone:706-244-0390
Mailing Address - Fax:
Practice Address - Street 1:163 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6820
Practice Address - Country:US
Practice Address - Phone:706-282-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN134100367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00291614OtherRAILROAD MEDICARE
GA579195040BMedicaid
511I430108Medicare PIN