Healthcare Provider Details

I. General information

NPI: 1275499790
Provider Name (Legal Business Name): SAM SHERRILL III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2025
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 OLD TOWN LN
BRANDON MS
39042-3658
US

IV. Provider business mailing address

202 OLD TOWN LN
BRANDON MS
39042-3658
US

V. Phone/Fax

Practice location:
  • Phone: 601-259-3254
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number902010
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: