Healthcare Provider Details

I. General information

NPI: 1326370446
Provider Name (Legal Business Name): JOHN A MOYER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2010
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 RIVER RD
GREENWOOD MS
38930-4030
US

IV. Provider business mailing address

1401 RIVER RD
GREENWOOD MS
38930-4030
US

V. Phone/Fax

Practice location:
  • Phone: 662-459-2613
  • Fax: 662-459-1159
Mailing address:
  • Phone: 662-459-2613
  • Fax: 662-459-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberA810332
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: