Provider Demographics
NPI:1407195225
Name:REDDING, JOHN BRAXTON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BRAXTON
Last Name:REDDING
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 73709
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3709
Mailing Address - Country:US
Mailing Address - Phone:770-251-2060
Mailing Address - Fax:678-854-9235
Practice Address - Street 1:1499 FAIR RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1683
Practice Address - Country:US
Practice Address - Phone:912-486-1973
Practice Address - Fax:912-681-4184
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-14
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN195323367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered