Provider Demographics
NPI:1679645352
Name:PLASTIC CRNA, LLC
Entity Type:Organization
Organization Name:PLASTIC CRNA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:H
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-484-2459
Mailing Address - Street 1:5002 HIGHWAY 39 N BLDG D
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-1078
Mailing Address - Country:US
Mailing Address - Phone:601-484-2459
Mailing Address - Fax:601-485-1698
Practice Address - Street 1:5002 HIGHWAY 39 N BLDG D
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1078
Practice Address - Country:US
Practice Address - Phone:601-484-2459
Practice Address - Fax:601-485-1698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSDG7434OtherRAILROAD MEDICARE
MSDG7434OtherRAILROAD MEDICARE