Provider Demographics
NPI:1679715551
Name:TROTTER, JASON T (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:TROTTER
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9253
Practice Address - Country:US
Practice Address - Phone:217-258-2440
Practice Address - Fax:217-258-2186
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008865367500000X
IN28219730A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered