Provider Demographics
NPI:1154340776
Name:CROMWELL, WILLIAM JODY SR (CRNA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JODY
Last Name:CROMWELL
Suffix:SR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-2417
Mailing Address - Country:US
Mailing Address - Phone:662-456-1163
Mailing Address - Fax:
Practice Address - Street 1:1002 E MADISON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2417
Practice Address - Country:US
Practice Address - Phone:662-456-1163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR535672367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013354Medicaid
MS1366465502OtherTRACE HOSPITAL NPI
MSC00717Medicare PIN
MS1366465502OtherTRACE HOSPITAL NPI