Provider Demographics
NPI:1306272976
Name:GARDNER, GRAHAM T (CRNA)
Entity type:Individual
Prefix:
First Name:GRAHAM
Middle Name:T
Last Name:GARDNER
Suffix:
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 1:4 WILLOW PT STE 1B
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1150
Mailing Address - Country:US
Mailing Address - Phone:601-987-6580
Mailing Address - Fax:
Practice Address - Street 1:4 WILLOW PT STE 1B
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1150
Practice Address - Country:US
Practice Address - Phone:601-987-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876117367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered