Healthcare Provider Details

I. General information

NPI: 1164441788
Provider Name (Legal Business Name): RICKY PAUL GAULT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 EARL FRYE BLVD
AMORY MS
38821-5500
US

IV. Provider business mailing address

123 MAIN ST N
AMORY MS
38821-3416
US

V. Phone/Fax

Practice location:
  • Phone: 662-256-7111
  • Fax:
Mailing address:
  • Phone: 662-256-7112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR619078
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: