Provider Demographics
NPI:1043374754
Name:DORNAN, JOHN S (NP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:DORNAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8489
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-0034
Mailing Address - Country:US
Mailing Address - Phone:662-240-0650
Mailing Address - Fax:662-240-0483
Practice Address - Street 1:425 HOSPITAL DR
Practice Address - Street 2:SUITE 4
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1901
Practice Address - Country:US
Practice Address - Phone:662-240-0650
Practice Address - Fax:662-240-0483
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853422363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118261Medicaid
MS00118261Medicaid