Provider Demographics
NPI:1346444676
Name:ALLEN, JAMES W (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:W
Last Name:ALLEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:JIM
Other - Middle Name:
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:182 LAKE TEHAMA TRL
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:GA
Mailing Address - Zip Code:30547-2250
Mailing Address - Country:US
Mailing Address - Phone:706-677-2019
Mailing Address - Fax:
Practice Address - Street 1:182 LAKE TEHAMA TRL
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:GA
Practice Address - Zip Code:30547-2250
Practice Address - Country:US
Practice Address - Phone:706-677-2019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032201367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000808244AMedicaid
GALICENSE NUMBEROther032201
43ZCBBV02Medicare UPIN