| NPI | 1205334331 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LORETTA C HARRELL Billing Manager 662-501-0043 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9104322) |
| Enumeration Date | 2018-01-23 |
| Last Update Date | 2018-01-23 |