Provider Demographics
NPI:1932748688
Name:GAULT, LEVI JORDAN (CRNA)
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:JORDAN
Last Name:GAULT
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 1:11393 HAWKSTOWE LN
Mailing Address - Street 2:
Mailing Address - City:FARRAGUT
Mailing Address - State:TN
Mailing Address - Zip Code:37934-4838
Mailing Address - Country:US
Mailing Address - Phone:865-368-9056
Mailing Address - Fax:
Practice Address - Street 1:9352 PARK WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4325
Practice Address - Country:US
Practice Address - Phone:865-373-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-29
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000027112367500000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program