Provider Demographics
NPI:1790721876
Name:BACKUS, PAUL ROGER (CRNA)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ROGER
Last Name:BACKUS
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 1:12752 KINGSTON PIKE
Mailing Address - Street 2:STE E202
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-0948
Mailing Address - Country:US
Mailing Address - Phone:865-777-0909
Mailing Address - Fax:865-777-0910
Practice Address - Street 1:550 FORT LOUDOUN MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5673
Practice Address - Country:US
Practice Address - Phone:865-777-0909
Practice Address - Fax:865-777-0910
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN51127367500000X
KY5986A367500000X
TN9088367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3037713OtherBLUECARE
TN3600330Medicaid
TN100021676OtherPHP TENNCARE
TN430009899OtherMEDICARE TRAVELERS
TN1502526Medicaid
TN3037713OtherBLUE CROSS
TN4173676OtherBLUE CROSS/BLUE SHIELD
KY000000616087OtherBLUE CROSS/BLUE SHIELD
KYP00810612OtherRAILROAD MEDICARE PIN
TNP00479791OtherRAILROAD MEDICARE PIN
TN3600360Medicare PIN
TN3600330Medicaid
KY0907328Medicare PIN