Healthcare Provider Details

I. General information

NPI: 1073578084
Provider Name (Legal Business Name): ANCE O. HAWKINS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 03/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 N STATE ST SUITE 203
JACKSON MS
39202-1658
US

IV. Provider business mailing address

1421 N STATE ST SUITE 203
JACKSON MS
39202-1658
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-1234
  • Fax: 601-326-3537
Mailing address:
  • Phone: 601-355-1234
  • Fax: 601-326-3537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR855028
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: