Basic Information
| Provider Information | |||||||||
| NPI: | 1629189949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOCKHART | ||||||||
| FirstName: | GEOFFREY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1818 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392151818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622937670 | ||||||||
| FaxNumber: | 6622934310 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 ALCORN DR | ||||||||
| Address2: | |||||||||
| City: | CORINTH | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388349368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622937670 | ||||||||
| FaxNumber: | 6622934310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | R853910 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 04522879 | 05 | MS | MEDICAID |