Basic Information
| Provider Information | |||||||||
| NPI: | 1306272976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | GRAHAM | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22505 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392252505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342791450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5001 HARDY ST | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342791450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2013 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R876117 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.