Provider Demographics
NPI:1518063007
Name:BROWN, WILLIE M JR (CRNA)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:M
Last Name:BROWN
Suffix:JR
Gender:
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:ONE GI CREDENTIALING DEPARTMENT
Mailing Address - Street 2:PO BOX 381468
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-4258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27A MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3949
Practice Address - Country:US
Practice Address - Phone:731-280-0157
Practice Address - Fax:731-424-0774
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11499367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3636774Medicaid
TN3636774Medicaid
TNP00429939OtherRAILROAD MEDICARE