Provider Demographics
NPI:1609016187
Name:DAVIDSON, JUSTIN MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:DAVIDSON
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:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-0629
Mailing Address - Country:US
Mailing Address - Phone:478-929-0036
Mailing Address - Fax:478-352-0095
Practice Address - Street 1:2594 NORTHERN OAK DR
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-6058
Practice Address - Country:US
Practice Address - Phone:404-731-9686
Practice Address - Fax:478-352-0095
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170478367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered