Provider Demographics
NPI:1598108896
Name:WALLACE, CRAWFORD REED JR (CRNA)
Entity Type:Individual
Prefix:
First Name:CRAWFORD
Middle Name:REED
Last Name:WALLACE
Suffix:JR
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 1:32 CLEAR SKY DR
Mailing Address - Street 2:
Mailing Address - City:CARRIERE
Mailing Address - State:MS
Mailing Address - Zip Code:39426-7818
Mailing Address - Country:US
Mailing Address - Phone:601-337-0700
Mailing Address - Fax:
Practice Address - Street 1:32 CLEAR SKY DR
Practice Address - Street 2:
Practice Address - City:CARRIERE
Practice Address - State:MS
Practice Address - Zip Code:39426-7818
Practice Address - Country:US
Practice Address - Phone:601-337-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR881469163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty