Healthcare Provider Details

I. General information

NPI: 1215746698
Provider Name (Legal Business Name): JONATHAN BROCKMEYER MARDIS DNP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2024
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

IV. Provider business mailing address

1290 W GOVERNMENT ST APT T158
BRANDON MS
39042-2445
US

V. Phone/Fax

Practice location:
  • Phone: 601-261-3606
  • Fax: 601-579-5383
Mailing address:
  • Phone: 601-938-0322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number152511
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: