Provider Demographics
NPI:1629189949
Name:LOCKHART, GEOFFREY R (CRNA)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:R
Last Name:LOCKHART
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:PO BOX 1818
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39215-1818
Mailing Address - Country:US
Mailing Address - Phone:662-293-7670
Mailing Address - Fax:662-293-4310
Practice Address - Street 1:611 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9368
Practice Address - Country:US
Practice Address - Phone:662-293-7670
Practice Address - Fax:662-293-4310
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853910367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04522879Medicaid