Provider Demographics
NPI:1205169521
Name:WILLOW ANESTHESIA SERVICES, LLC
Entity type:Organization
Organization Name:WILLOW ANESTHESIA SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:MCCULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:662-550-4299
Mailing Address - Street 1:2704 W OXFORD LOOP
Mailing Address - Street 2:SUITE 117
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5714
Mailing Address - Country:US
Mailing Address - Phone:662-550-4299
Mailing Address - Fax:662-580-4324
Practice Address - Street 1:2704 W OXFORD LOOP
Practice Address - Street 2:SUITE 117
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5714
Practice Address - Country:US
Practice Address - Phone:662-550-4299
Practice Address - Fax:662-580-4324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-18
Last Update Date:2019-07-11
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
DP9729OtherRR MEDICARE
MS02537897Medicaid
302G701987Medicare PIN