Provider Demographics
NPI:1417966953
Name:ANNIS, JASON PAUL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:PAUL
Last Name:ANNIS
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 1:3100 SPRING FOREST RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-873-9533
Mailing Address - Fax:
Practice Address - Street 1:1705 TARBORO ST SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3428
Practice Address - Country:US
Practice Address - Phone:252-399-8040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172062163W00000X
NC073396367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00600549OtherRAILROAD MEDICARE
NC8052801Medicaid
NCP00600549OtherRAILROAD MEDICARE
NC2615259Medicare PIN