Individual
MR. JERRY L MIXON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
4920 NE STALLINGS DR, NACOGDOCHES, TX 75965-1254
(936) 569-9481
(936) 462-4333
Mailing address
PO BOX 632114, NACOGDOCHES, TX 75963-2114
(936) 568-0087
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
227393
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
088527903
—
TX
01
—
88693U
BCBS
TX
Enumeration date
09/21/2006
Last updated
03/02/2009
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