Healthcare Provider Details

I. General information

NPI: 1437523958
Provider Name (Legal Business Name): JAMES SULLIVAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2015
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 13TH ST
GULFPORT MS
39501-2515
US

IV. Provider business mailing address

4500 13TH ST
GULFPORT MS
39501-2515
US

V. Phone/Fax

Practice location:
  • Phone: 228-867-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR882067
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number901358
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: