Provider Demographics
NPI:1811081649
Name:LAVERTY, JONATHAN D (CRNA)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:D
Last Name:LAVERTY
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 1:1011 HARDIN HOLLY
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-8985
Mailing Address - Country:US
Mailing Address - Phone:502-222-1170
Mailing Address - Fax:502-222-8647
Practice Address - Street 1:1025 NEW MOODY LN
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9154
Practice Address - Country:US
Practice Address - Phone:502-222-3886
Practice Address - Fax:502-222-8647
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1089893367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74028028Medicaid
KY000000375186OtherGLAS/DT KY PRVD #
KY1138502Medicaid
KY000000188229OtherABCBS PROVIDER #
KY0663602Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
KY74028028Medicaid