Provider Demographics
NPI:1982362786
Name:REDD, JUSTIN (CRNA, DNP)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:REDD
Suffix:
Gender:M
Credentials:CRNA, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CYPRESS CIR APT B
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5978
Mailing Address - Country:US
Mailing Address - Phone:801-613-2217
Mailing Address - Fax:
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-5811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA133868367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered