Provider Demographics
NPI:1326531229
Name:WALKER, JOHN (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WALKER
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 1:10737 BUFFALO RIVER CV
Mailing Address - Street 2:
Mailing Address - City:LAKE CORMORANT
Mailing Address - State:MS
Mailing Address - Zip Code:38641-9414
Mailing Address - Country:US
Mailing Address - Phone:901-282-9262
Mailing Address - Fax:
Practice Address - Street 1:7601 SOUTHCREST PKWY
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4739
Practice Address - Country:US
Practice Address - Phone:662-772-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS885832163WC0200X
MS901515367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine