Provider Demographics
NPI:1669642096
Name:RAINER, JAMES MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:RAINER
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 1:1421 N STATE ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1658
Mailing Address - Country:US
Mailing Address - Phone:601-355-1234
Mailing Address - Fax:601-326-3537
Practice Address - Street 1:1815 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3709
Practice Address - Country:US
Practice Address - Phone:601-638-8801
Practice Address - Fax:601-326-3537
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR503886367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04833363Medicaid
MS04833363Medicaid