Basic Information
| Provider Information | |||||||||
| NPI: | 1679750525 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 971 LAKELAND DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013621990 | ||||||||
| FaxNumber: | 6013621988 | ||||||||
| Practice Location | |||||||||
| Address1: | 971 LAKELAND DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013621990 | ||||||||
| FaxNumber: | 6013621988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
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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 | R867827 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | R867827 | 01 | RN LICENSE | OTHER |