Basic Information
| Provider Information | |||||||||
| NPI: | 1740649011 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6225 N STATE HIGHWAY 161 | ||||||||
| Address2: | NORTHSTAR ANESTHESIA OF OHIO, LLC, SUITE 200 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146870001 | ||||||||
| FaxNumber: | 9725182100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1995 EAST STATE STREET | ||||||||
| Address2: | SALEM REGIONAL MEDICAL CENTER | ||||||||
| City: | SALEM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303321551 | ||||||||
| FaxNumber: | 3303327899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2016 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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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 | 163W00000X | RN.396530-1 | OH | N | Nursing Service Providers | Registered Nurse | 367500000X | COA.18640-NA | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.