=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124070719
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROY CURTIS GAVIN CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2006
-----------------------------------------------------
Last Update Date | 02/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2046 BEACH BLVD APT C113
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39531-5126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-801-5526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2046 BEACH BLVD APT C113
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39531-5126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-801-5526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | AP04871
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | RN113738
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | R863777
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------