Provider Demographics
NPI:1740393396
Name:WILLIAMSON, RUSSELL N (CRNA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:N
Last Name:WILLIAMSON
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 1:9360 COLLINSVILLE CIR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39325-9174
Mailing Address - Country:US
Mailing Address - Phone:601-626-0162
Mailing Address - Fax:
Practice Address - Street 1:2124 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4040
Practice Address - Country:US
Practice Address - Phone:601-553-6000
Practice Address - Fax:601-553-6115
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR781015367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL730-02678OtherBLUE CROSS OF AL
MS00121569Medicaid
AL009974680Medicaid
AL009974680Medicaid
P02039Medicare UPIN
MS430001093Medicare ID - Type Unspecified