Healthcare Provider Details

I. General information

NPI: 1609105196
Provider Name (Legal Business Name): JOSEPH BYRON TULLOS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HIGHWAY 16 E
CARTHAGE MS
39051-4222
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 601-267-1470
  • Fax: 601-267-1469
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR866137
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: