Provider Demographics
NPI:1407179609
Name:BROWN, ROGER LEE JR (CRNA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:LEE
Last Name:BROWN
Suffix:JR
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 105048
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30348-5048
Mailing Address - Country:US
Mailing Address - Phone:800-919-1190
Mailing Address - Fax:706-860-6484
Practice Address - Street 1:3000 HOSPITAL BLVD
Practice Address - Street 2:ANESTHESIA DEPT.
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4915
Practice Address - Country:US
Practice Address - Phone:770-751-2623
Practice Address - Fax:770-751-2627
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN163820367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN163820OtherRN / CRNA LICENSE