Healthcare Provider Details

I. General information

NPI: 1588747489
Provider Name (Legal Business Name): VINCENT GUY LOMBARDO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 GOODYEAR BLVD
PICAYUNE MS
39466
US

IV. Provider business mailing address

PO BOX 909 801 GOODYEAR BLVD
PICAYUNE MS
39466
US

V. Phone/Fax

Practice location:
  • Phone: 601-798-4711
  • Fax: 601-749-3187
Mailing address:
  • Phone: 601-798-4711
  • Fax: 601-749-3187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR854721
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: