Provider Demographics
NPI:1881634699
Name:GORANSON, EDWIN H (CRNA)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:H
Last Name:GORANSON
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 1:443 OAKDALE DR
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-8063
Mailing Address - Country:US
Mailing Address - Phone:843-332-0780
Mailing Address - Fax:
Practice Address - Street 1:1304 W BOBO NEWSOM HWY
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4710
Practice Address - Country:US
Practice Address - Phone:843-339-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR51873367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0380Medicaid
SCAN0380Medicaid