Provider Demographics
NPI:1548465982
Name:DURST, PHILLIP THORNTON (CRNA)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:THORNTON
Last Name:DURST
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 1:1022 WELLESLEY CREST DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6710
Mailing Address - Country:US
Mailing Address - Phone:678-494-4074
Mailing Address - Fax:
Practice Address - Street 1:1022 WELLESLEY CREST DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6710
Practice Address - Country:US
Practice Address - Phone:678-494-4074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN038761 CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered