Healthcare Provider Details

I. General information

NPI: 1699441980
Provider Name (Legal Business Name): BAILEY VOUGHN STOKES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BROAD AVE STE 330
GULFPORT MS
39501
US

IV. Provider business mailing address

PO BOX 1810
GULFPORT MS
39502
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-1234
  • Fax: 228-867-4828
Mailing address:
  • Phone: 228-575-1194
  • Fax: 228-575-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00676
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: