Healthcare Provider Details

I. General information

NPI: 1144231325
Provider Name (Legal Business Name): JOE R MARTIN JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 14TH ST
MERIDIAN MS
39301-4040
US

IV. Provider business mailing address

7925A VAN ZYVERDEN RD
MERIDIAN MS
39305-9124
US

V. Phone/Fax

Practice location:
  • Phone: 601-553-6000
  • Fax: 601-553-6115
Mailing address:
  • Phone: 601-679-9849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR853128
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: