Basic Information
| Provider Information | |||||||||
| NPI: | 1790721876 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACKUS | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | ROGER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12752 KINGSTON PIKE | ||||||||
| Address2: | STE E202 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379340948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657770909 | ||||||||
| FaxNumber: | 8657770910 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 FORT LOUDOUN MEDICAL CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | LENOIR CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377725673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657770909 | ||||||||
| FaxNumber: | 8657770910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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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 | 51127 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 5986A | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 9088 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3037713 | 01 | TN | BLUECARE | OTHER | 3600330 | 05 | TN | MEDICAID | 100021676 | 01 | TN | PHP TENNCARE | OTHER | 430009899 | 01 | TN | MEDICARE TRAVELERS | OTHER | 1502526 | 05 | TN | MEDICAID | 3037713 | 01 | TN | BLUE CROSS | OTHER | 4173676 | 01 | TN | BLUE CROSS/BLUE SHIELD | OTHER | 000000616087 | 01 | KY | BLUE CROSS/BLUE SHIELD | OTHER | P00810612 | 01 | KY | RAILROAD MEDICARE PIN | OTHER | P00479791 | 01 | TN | RAILROAD MEDICARE PIN | OTHER |