Provider Demographics
NPI:1972598415
Name:SUTHERLIN, RICHARD D III (CRNA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:SUTHERLIN
Suffix:III
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 1:518 COLLEGE HILL RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-2026
Mailing Address - Country:US
Mailing Address - Phone:662-801-1516
Mailing Address - Fax:
Practice Address - Street 1:518 COLLEGE HILL RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-2026
Practice Address - Country:US
Practice Address - Phone:662-801-1516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR861446367500000X
MEAA113017367500000X
TXAP120679367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS430001891Medicare ID - Type Unspecified