Healthcare Provider Details

I. General information

NPI: 1154961340
Provider Name (Legal Business Name): WILLIAM BRENT MILEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 CHADWICK DRIVE
JACKSON MS
39204
US

IV. Provider business mailing address

P.O. BOX 235019
MONTGOMERY AL
36123
US

V. Phone/Fax

Practice location:
  • Phone: 334-279-1450
  • Fax: 334-279-1660
Mailing address:
  • Phone: 334-279-1450
  • Fax: 334-279-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number882885
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: