Provider Demographics
NPI:1194954230
Name:WILLIAMS, JEREMY O (CRNA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:O
Last Name:WILLIAMS
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 23605
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33623-3605
Mailing Address - Country:US
Mailing Address - Phone:888-533-0566
Mailing Address - Fax:913-341-5797
Practice Address - Street 1:3100 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4613
Practice Address - Country:US
Practice Address - Phone:813-615-7848
Practice Address - Fax:913-341-5797
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9282260367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001697900Medicaid
FLG000MOtherBCBS
FL001697900Medicaid