Provider Demographics
NPI:1003205238
Name:MCREYNOLDS, MICHAEL J (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:MCREYNOLDS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 BRITTON CIR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8110
Mailing Address - Country:US
Mailing Address - Phone:571-330-1646
Mailing Address - Fax:
Practice Address - Street 1:2100 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8211
Practice Address - Country:US
Practice Address - Phone:601-831-1146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR880370367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered