Healthcare Provider Details

I. General information

NPI: 1881768059
Provider Name (Legal Business Name): LUCIUS LEWIS JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 HOSPITAL DR
CLARKSDALE MS
38614-7202
US

IV. Provider business mailing address

103 THORNWOOD DR
CLINTON MS
39056-6226
US

V. Phone/Fax

Practice location:
  • Phone: 662-624-3401
  • Fax: 662-627-5440
Mailing address:
  • Phone: 662-588-0277
  • Fax: 804-545-0652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR868756
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: