Healthcare Provider Details

I. General information

NPI: 1871878967
Provider Name (Legal Business Name): GEORGE CROUSE FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BROOKMAN DR EXT SUITE A
BROOKHAVEN MS
39601-2371
US

IV. Provider business mailing address

601 BROOKMAN DR EXT SUITE A
BROOKHAVEN MS
39601-2371
US

V. Phone/Fax

Practice location:
  • Phone: 601-823-5275
  • Fax: 601-823-2206
Mailing address:
  • Phone: 601-823-5275
  • Fax: 601-823-2206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR870311
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: