Provider Demographics
NPI:1598875767
Name:MUSSELWHITE, CHARLES (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MUSSELWHITE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:MUSSLEWHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 1684
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39568-1684
Mailing Address - Country:US
Mailing Address - Phone:228-762-9080
Mailing Address - Fax:228-762-0065
Practice Address - Street 1:3882 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5803
Practice Address - Country:US
Practice Address - Phone:228-872-6290
Practice Address - Fax:228-762-0065
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR741121367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS430064344OtherMEDICARE RAILROAD
MS009994055OtherALACAID
MS0115359Medicaid
169045200OtherUSDOL
MS587210340COtherAHS STATE
MS587210340COtherBLUE CROSS
MS587210340COtherAHS STATE