Provider Demographics
NPI:1184636730
Name:COLLINS, MARY W (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:COLLINS
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 1:2124 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4040
Mailing Address - Country:US
Mailing Address - Phone:601-485-1131
Mailing Address - Fax:601-485-1336
Practice Address - Street 1:1926 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3107
Practice Address - Country:US
Practice Address - Phone:601-485-1131
Practice Address - Fax:601-485-1336
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851820367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00127115Medicaid
GAP00339767OtherRAILROAD MEDICARE
MS00127115Medicaid
MSP55448Medicare UPIN