Provider Demographics
NPI:1932189628
Name:STEPHENS, LARRY D JR (CRNA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:STEPHENS
Suffix:JR
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 1:1053 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9595
Mailing Address - Country:US
Mailing Address - Phone:601-969-1430
Mailing Address - Fax:601-709-2117
Practice Address - Street 1:1053 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9595
Practice Address - Country:US
Practice Address - Phone:601-969-1430
Practice Address - Fax:601-709-2117
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021351367500000X
MSR852085367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122204Medicaid
430002052OtherMEDICARE
430002052OtherMEDICARE