Healthcare Provider Details

I. General information

NPI: 1851674097
Provider Name (Legal Business Name): HARALD JORGE SAMPSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6952 APUWAI PL
DIAMONDHEAD MS
39525-3513
US

IV. Provider business mailing address

6952 APUWAI PL
DIAMONDHEAD MS
39525-3513
US

V. Phone/Fax

Practice location:
  • Phone: 228-493-2490
  • Fax:
Mailing address:
  • Phone: 228-493-2490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR868903
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: