Provider Demographics
NPI:1427137280
Name:WEST TENNESSEE ANESTHESIA, PC
Entity type:Organization
Organization Name:WEST TENNESSEE ANESTHESIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:731-664-1717
Mailing Address - Street 1:17C BRENTSHIRE SQUARE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2273
Mailing Address - Country:US
Mailing Address - Phone:731-664-1717
Mailing Address - Fax:731-664-7114
Practice Address - Street 1:17C BRENTSHIRE SQUARE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2273
Practice Address - Country:US
Practice Address - Phone:731-664-1717
Practice Address - Fax:731-664-7114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3604177Medicaid
TN3604177Medicare ID - Type Unspecified