Provider Demographics
NPI:1720644743
Name:COLE, JEREMIAH (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:COLE
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 1:1068 CRESTHAVEN RD STE 150
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3859
Mailing Address - Country:US
Mailing Address - Phone:901-682-6828
Mailing Address - Fax:901-682-9316
Practice Address - Street 1:1068 CRESTHAVEN RD STE 150
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3859
Practice Address - Country:US
Practice Address - Phone:901-682-6828
Practice Address - Fax:901-682-9316
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN184971367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered