Provider Demographics
NPI:1932576550
Name:EZELLE, CHARLES (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:EZELLE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 W OXFORD LOOP
Mailing Address - Street 2:SUITE 117
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5714
Mailing Address - Country:US
Mailing Address - Phone:662-550-4299
Mailing Address - Fax:662-580-4324
Practice Address - Street 1:2704 W OXFORD LOOP
Practice Address - Street 2:SUITE 117
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5714
Practice Address - Country:US
Practice Address - Phone:662-550-4299
Practice Address - Fax:662-580-4324
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR880502367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered