Basic Information
| Provider Information | |||||||||
| NPI: | 1184698904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1707 | ||||||||
| Address2: | |||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310591707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784572036 | ||||||||
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| Practice Location | |||||||||
| Address1: | 821 N COBB ST | ||||||||
| Address2: | |||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310612343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784572036 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 06/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN040553 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 00562119B | 05 | GA | MEDICAID | 430070535 | 01 | GA | MCRB RAILROAD | OTHER |