Provider Demographics
NPI:1508960295
Name:GHATAS, AUDREY DONNA (CRNA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:DONNA
Last Name:GHATAS
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:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:MS
Mailing Address - Zip Code:39119-0669
Mailing Address - Country:US
Mailing Address - Phone:601-466-3601
Mailing Address - Fax:601-797-9993
Practice Address - Street 1:300 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3665
Practice Address - Country:US
Practice Address - Phone:601-849-7173
Practice Address - Fax:601-849-7353
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR125620367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00110086Medicaid
MSR34695Medicare UPIN
MS00110086Medicaid