Provider Demographics
NPI:1770502213
Name:LOVERN, DOUGLAS ALLAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ALLAN
Last Name:LOVERN
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 5371
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-5371
Mailing Address - Country:US
Mailing Address - Phone:601-992-1801
Mailing Address - Fax:
Practice Address - Street 1:766 LAKELAND DR STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4610
Practice Address - Country:US
Practice Address - Phone:601-368-3440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR801579367500000X
MS902973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03037303Medicaid
MSP00745655OtherMEDICARE RAILROAD
MS512I430308Medicare PIN