Healthcare Provider Details

I. General information

NPI: 1326531229
Provider Name (Legal Business Name): JOHN WALKER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 SOUTHCREST PKWY
SOUTHAVEN MS
38671-4739
US

IV. Provider business mailing address

10737 BUFFALO RIVER CV
LAKE CORMORANT MS
38641-9414
US

V. Phone/Fax

Practice location:
  • Phone: 662-772-4000
  • Fax:
Mailing address:
  • Phone: 901-282-9262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number885832
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number901515
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: