Provider Demographics
NPI:1871917294
Name:GRAHAM, CORNELL (CRNA)
Entity type:Individual
Prefix:
First Name:CORNELL
Middle Name:
Last Name:GRAHAM
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5952
Mailing Address - Fax:601-984-5939
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPARTMENT OF ANESTHESIA
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5952
Practice Address - Fax:601-984-5939
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2723367500000X
MSR880851367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09739086Medicaid
LA2406230Medicaid
MSP01590551OtherRAILROAD MEDICARE
LA2406230Medicaid
MS374065YX3DMedicare PIN