Provider Demographics
NPI:1538639984
Name:AVERETT, JAMES WELBY (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WELBY
Last Name:AVERETT
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 1:309 S 64TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-6984
Mailing Address - Country:US
Mailing Address - Phone:801-830-3714
Mailing Address - Fax:
Practice Address - Street 1:4104 WENVIEW CT
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353-6000
Practice Address - Country:US
Practice Address - Phone:801-830-3714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX895386163W00000X
OK125367163W00000X
WAAP60929524367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse