Provider Demographics
NPI:1518014166
Name:DANIELS, JEREMIAH WESLEY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:WESLEY
Last Name:DANIELS
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 1:415 SOUTH 28TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401
Mailing Address - Country:US
Mailing Address - Phone:601-261-3606
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-261-3606
Practice Address - Fax:601-579-5383
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9215601163W00000X
GARN187112163W00000X, 367500000X
MS901433367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1952395097OtherNORTH GEORGIA MEDICAL CENTER NPI
MS02323776Medicaid
GARN187112OtherRN LICENSE
GA58-1896463OtherNORTH GEORGIA MEDICAL CENTER, TAX ID