Provider Demographics
NPI:1588700579
Name:MCCRELESS, JOHN BLAKE (CRNA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BLAKE
Last Name:MCCRELESS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1104 GOODYEAR AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-2059
Mailing Address - Country:US
Mailing Address - Phone:256-494-1514
Mailing Address - Fax:
Practice Address - Street 1:1007 GOODYEAR AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1195
Practice Address - Country:US
Practice Address - Phone:256-494-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-087231367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered