Provider Demographics
NPI:1306945944
Name:MIXON, JERRY L (CRNA)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:L
Last Name:MIXON
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 632114
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-2114
Mailing Address - Country:US
Mailing Address - Phone:936-568-0087
Mailing Address - Fax:
Practice Address - Street 1:4920 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1254
Practice Address - Country:US
Practice Address - Phone:936-569-9481
Practice Address - Fax:936-462-4333
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX227393367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX088527903Medicaid
TX88693UOtherBCBS
TX88693UOtherBCBS