MEDICARE: GRAHAM T GARDNER CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	R876117	MS

General Provider Information

NPI Number	:	1306272976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRAHAM T GARDNER CRNA

Provider Business Mailing Address
First Line	:	4 WILLOW PT STE 1B
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1150
Country	:	US
Telephone Number	:	601-987-6580
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 WILLOW PT STE 1B
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1150
Country	:	US
Telephone Number	:	601-987-6580
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2013
Last Update Date	:	12/04/2023

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