Provider Demographics
NPI:1164416962
Name:SMITH, MARCIA R (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 FATHER RYAN AVE
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530-3656
Mailing Address - Country:US
Mailing Address - Phone:228-376-4458
Mailing Address - Fax:
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:228-376-4458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX552825367500000X
MS901411367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVAD000Medicare UPIN