Provider Demographics
NPI:1801832506
Name:POULSON, JON BOYD (CRNA)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:BOYD
Last Name:POULSON
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 1:101 RIVERSIDE LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-1448
Mailing Address - Country:US
Mailing Address - Phone:740-336-9201
Mailing Address - Fax:
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-568-5427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV56808367500000X
OHRN233430367500000X
OHAPRN.CRNA.06711367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0207026000OtherGROUP MEDICAID
WV9333201OtherMEDICARE GROUP
OH2300165Medicaid
WV2604134000Medicaid
WV9333201OtherMEDICARE GROUP
OH8229533Medicare PIN