Provider Demographics
NPI:1871606392
Name:HARDISON, JR., PHILIP LEE (CRNA)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:LEE
Last Name:HARDISON, JR.
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:190 CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-9523
Mailing Address - Country:US
Mailing Address - Phone:541-673-0260
Mailing Address - Fax:
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6523
Practice Address - Country:US
Practice Address - Phone:541-440-1000
Practice Address - Fax:541-677-3189
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered