Provider Demographics
NPI:1538464086
Name:CROUCH, JEREMY KEITH (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:KEITH
Last Name:CROUCH
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 1:5001 WELLINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-5409
Mailing Address - Country:US
Mailing Address - Phone:931-260-1965
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD BLDG 9250
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:762-408-0455
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN085227367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered