Provider Demographics
NPI:1306105390
Name:CONNELL, DUSTIN (CRNA)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:CONNELL
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 1:276 BELFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1607
Mailing Address - Country:US
Mailing Address - Phone:229-392-8840
Mailing Address - Fax:478-333-6117
Practice Address - Street 1:901 18TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3648
Practice Address - Country:US
Practice Address - Phone:229-353-6124
Practice Address - Fax:229-353-7722
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN167296367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN167296OtherSTATE LICENSE