Provider Demographics
NPI:1477785079
Name:MCLEOD, DERRICK G (CRNA)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:G
Last Name:MCLEOD
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 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-362-1990
Mailing Address - Fax:601-362-1988
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 202
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-362-1990
Practice Address - Fax:601-362-1988
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872351367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered