Provider Demographics
NPI:1659316248
Name:BRISTER, LEIGH H (CRNA)
Entity type:Individual
Prefix:MRS
First Name:LEIGH
Middle Name:H
Last Name:BRISTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:LEIGH
Other - Middle Name:ELIZABETH
Other - Last Name:HERRINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:147 CARMICHAEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6368
Mailing Address - Country:US
Mailing Address - Phone:601-209-8272
Mailing Address - Fax:
Practice Address - Street 1:2500 N. STATE ST.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206
Practice Address - Country:US
Practice Address - Phone:601-984-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869571367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00975577Medicaid
MS00975577Medicaid
MS430002142Medicare ID - Type Unspecified