Provider Demographics
NPI:1255516126
Name:BARTLEY, DAVID M (CRNA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:BARTLEY
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 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-362-1990
Mailing Address - Fax:601-362-1988
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 202
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-362-1990
Practice Address - Fax:601-362-1988
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR864484367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR864484OtherRN LICENSE
MS302I433064Medicare PIN