Healthcare Provider Details

I. General information

NPI: 1821962440
Provider Name (Legal Business Name): MISSISSIPPI PRIMARY CARE MS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7112 S SIWELL RD STE C
BYRAM MS
39272-8744
US

IV. Provider business mailing address

7112 S SIWELL RD STE C
BYRAM MS
39272-8744
US

V. Phone/Fax

Practice location:
  • Phone: 601-622-5620
  • Fax: 601-510-3883
Mailing address:
  • Phone: 601-622-5620
  • Fax: 601-510-3883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHATINA MARTIN
Title or Position: NURSE PRACTITIONER/PROVIDER
Credential: NURSE PRACTITIONER
Phone: 601-622-5620