Provider Demographics
NPI:1952335572
Name:WELBORN, JERRY RYAN (CRNA)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:RYAN
Last Name:WELBORN
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:PO BOX 2045
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2045
Mailing Address - Country:US
Mailing Address - Phone:662-380-3513
Mailing Address - Fax:
Practice Address - Street 1:8375 HIGHWAY 72 W
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9573
Practice Address - Country:US
Practice Address - Phone:205-265-2012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR862001367500000X
AL1-134799367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered