Provider Demographics
NPI:1912956939
Name:BAXLEY, DOUGLAS O (CRNA)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:O
Last Name:BAXLEY
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 1:285 RHETT CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:AL
Mailing Address - Zip Code:36545-8703
Mailing Address - Country:US
Mailing Address - Phone:251-246-9594
Mailing Address - Fax:
Practice Address - Street 1:285 RHETT CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:AL
Practice Address - Zip Code:36545-8703
Practice Address - Country:US
Practice Address - Phone:251-246-9594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-056701367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000052741Medicaid
ALS68647Medicare UPIN
AL000035266Medicare ID - Type Unspecified