Healthcare Provider Details

I. General information

NPI: 1811743867
Provider Name (Legal Business Name): SHERMAN CHRISTIAN STAUFFER III DNP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 06/06/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 E BAKER ST
INDIANOLA MS
38751-2450
US

IV. Provider business mailing address

3259 TRACER LN
MEMPHIS TN
38119-9046
US

V. Phone/Fax

Practice location:
  • Phone: 662-887-5235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number901913
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number227374
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: