Healthcare Provider Details

I. General information

NPI: 1417276106
Provider Name (Legal Business Name): NATHAN LANCE NEWMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N BROAD ST
FOREST MS
39074-3508
US

IV. Provider business mailing address

330 N BROAD ST
FOREST MS
39074-3508
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4151
  • Fax:
Mailing address:
  • Phone: 601-469-4151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR871642
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: