Organization
MISSISSIPPI ANESTHESIA GROUP, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GARY DWAYNE SELF CRNA (FOUNDER AND PRESIDENT)
(601) 668-5628
Entity
Organization
Contact information
Practice address
145 SANCTUARY LN, CANTON, MS 39046-6601
(601) 855-7440
Mailing address
2714 W OXFORD LOOP, STE 161, OXFORD, MS 38655-5711
(662) 550-4299
(662) 580-4324
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
R598755
MS
Other
Enumeration date
10/01/2014
Last updated
10/01/2014
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