Provider Demographics
NPI:1386630440
Name:HINES, MARTHA B (CRNA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:B
Last Name:HINES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 MCINTOSH DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-7891
Mailing Address - Country:US
Mailing Address - Phone:731-664-4615
Mailing Address - Fax:
Practice Address - Street 1:367 HOSPITAL BLVD
Practice Address - Street 2:REGIONAL HOSPITAL OF JACKSON
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2080
Practice Address - Country:US
Practice Address - Phone:731-661-2227
Practice Address - Fax:731-661-2228
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11163367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3634950Medicaid
TN3634950Medicare ID - Type Unspecified