Provider Demographics
NPI:1407887045
Name:LAWRENCE, JEREMY S (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:S
Last Name:LAWRENCE
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:P.O. BOX 3488, DEPT. 05-003
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803
Mailing Address - Country:US
Mailing Address - Phone:334-386-2053
Mailing Address - Fax:334-244-1830
Practice Address - Street 1:499 AZALEA DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-7901
Practice Address - Country:US
Practice Address - Phone:662-234-7979
Practice Address - Fax:334-244-1830
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR859361367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSAPPLIED FORMedicare ID - Type UnspecifiedMEDICARE PROV #