Provider Demographics
NPI:1700202900
Name:GOSTNELL, JERRY W II (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:W
Last Name:GOSTNELL
Suffix:II
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 1:369 J BAR RUN
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-6465
Mailing Address - Country:US
Mailing Address - Phone:337-509-5409
Mailing Address - Fax:
Practice Address - Street 1:BAYNE-JONES ARMY COMMUNICTY HOSPITAL
Practice Address - Street 2:1585 THIRD ST
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459
Practice Address - Country:US
Practice Address - Phone:337-531-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA187722163W00000X
HI74288163W00000X
OHAPRN.CRNA.0020337367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse