Provider Demographics
NPI:1356410401
Name:MARTIN, JO ELLEN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:JO
Middle Name:ELLEN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:JO
Other - Middle Name:ELLEN
Other - Last Name:COLLIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:1417 TAYLOR THURSTON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39701
Mailing Address - Country:US
Mailing Address - Phone:662-328-7067
Mailing Address - Fax:
Practice Address - Street 1:835 MEDICAL CENTER DRIVE
Practice Address - Street 2:NORTH MISS MEDICAL CENTER WEST POINT
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773
Practice Address - Country:US
Practice Address - Phone:662-495-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR570613367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
43080018OtherMCRR
CRNA022775OtherAANA
MS0116137Medicaid
CRNA022775OtherAANA