Provider Demographics
NPI:1386732154
Name:CHANDLER, GARY H (CRNA)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:H
Last Name:CHANDLER
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 1:4810 STONEBRIDGE CV
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-9499
Mailing Address - Country:US
Mailing Address - Phone:662-841-2858
Mailing Address - Fax:
Practice Address - Street 1:200 STATE HIGHWAY 30 W
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3112
Practice Address - Country:US
Practice Address - Phone:662-538-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR743486367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125903Medicaid