Provider Demographics
NPI:1669402038
Name:FORT, LARRY MAX JR (CRNA)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:MAX
Last Name:FORT
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:MAX
Other - Middle Name:
Other - Last Name:FORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:2534 SAINT JAMES DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-6753
Mailing Address - Country:US
Mailing Address - Phone:615-585-6218
Mailing Address - Fax:
Practice Address - Street 1:4323 CAROTHERS PKWY STE 208
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-5916
Practice Address - Country:US
Practice Address - Phone:615-778-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10015367500000X
WI15554367500000X
TNAPN0000010015367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4067168OtherBLUE SHIELD
TN7235513OtherAETNA PPO
TN3626436Medicaid
TN7235513OtherAETNA PPO
TN3626438Medicare ID - Type UnspecifiedMEDICARE