Provider Demographics
NPI:1295799260
Name:EDMONDSON, JOHN THAYER (CRNA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THAYER
Last Name:EDMONDSON
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 1:2323 TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:TX
Mailing Address - Zip Code:79772-7338
Mailing Address - Country:US
Mailing Address - Phone:432-447-3551
Mailing Address - Fax:432-447-5434
Practice Address - Street 1:2323 TEXAS ST
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:TX
Practice Address - Zip Code:79772-7338
Practice Address - Country:US
Practice Address - Phone:432-447-3551
Practice Address - Fax:432-447-5434
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN043542367500000X
TXAP115284367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN023413OtherCRNA CERTIFICATION NUMBER
TX202890402Medicaid
TN023413OtherCRNA CERTIFICATION NUMBER