Healthcare Provider Details

I. General information

NPI: 1427439389
Provider Name (Legal Business Name): ERIC YEAGER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 HIGHWAY 61 N
VICKSBURG MS
39183-8211
US

IV. Provider business mailing address

1116 LINKS DR APT 3
JONESBORO AR
72404-0709
US

V. Phone/Fax

Practice location:
  • Phone: 601-883-5708
  • Fax:
Mailing address:
  • Phone: 318-348-5336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberA810666
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: