Provider Demographics
NPI:1215746698
Name:MARDIS, JONATHAN BROCKMEYER (DNP, CRNA)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:BROCKMEYER
Last Name:MARDIS
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Gender:M
Credentials:DNP, CRNA
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Mailing Address - Street 1:1290 W GOVERNMENT ST APT T158
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2445
Mailing Address - Country:US
Mailing Address - Phone:601-938-0322
Mailing Address - Fax:
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-384-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-31
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS152511367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered