Individual
MEVLUDIN BASIC
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
1265 UNION AVE, MEMPHIS, TN 38104-3415
(901) 725-5846
Mailing address
6060 PRIMACY PKWY, SUITE 241, MEMPHIS, TN 38119-5745
(901) 725-5846
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
131479
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02839011
—
MS
05
—
3634253
—
TN
01
—
4099081
BLUE CROSS
TN
01
—
P00194289
RAILROAD MEDICARE
—
Enumeration date
05/20/2006
Last updated
12/21/2016
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