Provider Demographics
NPI:1558492157
Name:SANDERS, JOE ALVIN (CRNA)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:ALVIN
Last Name:SANDERS
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 1:4581 THIRD DISTRICT RD
Mailing Address - Street 2:
Mailing Address - City:UNADILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31091-4139
Mailing Address - Country:US
Mailing Address - Phone:229-645-3495
Mailing Address - Fax:
Practice Address - Street 1:601 BLUEBIRD BLVD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-5082
Practice Address - Country:US
Practice Address - Phone:478-825-8691
Practice Address - Fax:478-825-4458
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113320367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000784979DMedicaid