Healthcare Provider Details

I. General information

NPI: 1598790974
Provider Name (Legal Business Name): JON T WALL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 JEFFERSON ST
LAUREL MS
39440-4355
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-426-4000
  • Fax: 601-426-4000
Mailing address:
  • Phone: 601-399-6167
  • Fax: 601-399-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR866388
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: