Provider Demographics
NPI:1881644367
Name:BURNHAM, JAMES GREGORY (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:GREGORY
Last Name:BURNHAM
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 1:246 OAKDALE RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7518
Mailing Address - Country:US
Mailing Address - Phone:601-829-0924
Mailing Address - Fax:660-826-4852
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5900
Practice Address - Fax:660-826-4852
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR859891367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS430002186Medicare PIN