Provider Demographics
NPI:1124400601
Name:DAMRON, JOSEPH ALEXANDER (CRNA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ALEXANDER
Last Name:DAMRON
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 1:1185 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1258
Mailing Address - Country:US
Mailing Address - Phone:501-680-7497
Mailing Address - Fax:
Practice Address - Street 1:2740 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6141
Practice Address - Country:US
Practice Address - Phone:501-329-5459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR096488163W00000X
SC24600367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse