Provider Demographics
NPI:1376582551
Name:FANNIN, JON S (CRNA)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:S
Last Name:FANNIN
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 1:420 WATER ST
Mailing Address - Street 2:105-B
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5200
Mailing Address - Country:US
Mailing Address - Phone:830-896-1344
Mailing Address - Fax:830-896-1363
Practice Address - Street 1:710 WATER ST
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5329
Practice Address - Country:US
Practice Address - Phone:830-896-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR43299367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J7990Medicare PIN