Provider Demographics
NPI:1669774667
Name:TAYLOR, ELDRIDGE L (CRNA)
Entity type:Individual
Prefix:MR
First Name:ELDRIDGE
Middle Name:L
Last Name:TAYLOR
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 1:225 JASMINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-3283
Mailing Address - Country:US
Mailing Address - Phone:601-212-9272
Mailing Address - Fax:
Practice Address - Street 1:225 JASMINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-3283
Practice Address - Country:US
Practice Address - Phone:601-212-9272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR864321367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03551301Medicaid