Provider Demographics
NPI:1376562934
Name:NORMAN, JOHN LEWIS (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LEWIS
Last Name:NORMAN
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:PO BOX 3305
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-3305
Mailing Address - Country:US
Mailing Address - Phone:229-891-9131
Mailing Address - Fax:229-889-1907
Practice Address - Street 1:3131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-591-9131
Practice Address - Fax:229-891-9079
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR051263367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00556685FMedicaid
GA000556685HMedicaid
GA639663690AMedicaid
GAR051263OtherLICENSE
GA43ZCBMH08Medicare PIN
GA43BBCTBMedicare PIN
GAR051263OtherLICENSE
GA00556685FMedicaid