Basic Information
Provider Information | |||||||||
NPI: | 1821084708 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LLEWELLYN | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 220 CAMPUS BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | WINCHESTER | ||||||||
State: | VA | ||||||||
PostalCode: | 226012896 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5405365100 | ||||||||
FaxNumber: | 5405360235 | ||||||||
Practice Location | |||||||||
Address1: | 500 W BERKELEY ST | ||||||||
Address2: |   | ||||||||
City: | UNIONTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 154015514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7244305803 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2005 | ||||||||
LastUpdateDate: | 08/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | RN352375L | PA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 367500000X | 85299 | WV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | R124304 | MD | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | RN352375L | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 050514 | 01 | PA | MEDICARE GROUP # | OTHER | 1821084708 | 01 |   | NPI | OTHER | 1007307260035 | 01 | PA | MEDICAID GROUP # | OTHER | RN352375L | 01 | PA | LICENSE | OTHER | 102319010 0003 | 05 | PA |   | MEDICAID |