Provider Demographics
NPI:1730513342
Name:GRIST, JONATHAN SCOTT (CRNA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SCOTT
Last Name:GRIST
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 BOARDMAN CANFIELD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9803
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-480-3658
Practice Address - Fax:330-480-3439
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC265331367500000X
OHRN356025-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1730513342Medicaid
NC185VNOtherBCBS
OHPENDINGOtherMEDICARE PTAN
OHPENDINGMedicaid
NCQ46282AMedicare PIN