Provider Demographics
NPI:1255443453
Name:PAYNE, ERIC O (CRNA)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:O
Last Name:PAYNE
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 1:1421 N STATE ST STE 203
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1658
Mailing Address - Country:US
Mailing Address - Phone:601-355-1234
Mailing Address - Fax:601-326-3559
Practice Address - Street 1:1421 N STATE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1658
Practice Address - Country:US
Practice Address - Phone:601-355-1234
Practice Address - Fax:601-326-3559
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871191367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00882999OtherRR MEDICIARE
MS07636002Medicaid
MS512I430187Medicare PIN
MS07636002Medicaid