Provider Demographics
NPI:1407837008
Name:SWENSON, JERRY ALAN (CRNA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:ALAN
Last Name:SWENSON
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 1:1936 PINEWOOD CV NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-1848
Mailing Address - Country:US
Mailing Address - Phone:423-476-2583
Mailing Address - Fax:
Practice Address - Street 1:1200 MEMORIAL DRIVE
Practice Address - Street 2:ANESTHESIA ASSOCIATES OF DALTON
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720
Practice Address - Country:US
Practice Address - Phone:706-272-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN61090367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3608461Medicare ID - Type Unspecified