Basic Information
| Provider Information | |||||||||
| NPI: | 1376513580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORBES | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 W FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316681853 | ||||||||
| FaxNumber: | 7316647731 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 W FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316681853 | ||||||||
| FaxNumber: | 7316647731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
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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 | 109677 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3624491 | 05 | TN | MEDICAID |