Healthcare Provider Details

I. General information

NPI: 1871839555
Provider Name (Legal Business Name): JOSHUA E FUQUA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5900
  • Fax:
Mailing address:
  • Phone: 601-984-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR874367
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: