Healthcare Provider Details

I. General information

NPI: 1467479550
Provider Name (Legal Business Name): JERRY LEE STORK P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3688 VETERANS MEMORIAL DR 200
HATTIESBURG MS
39401-8246
US

IV. Provider business mailing address

3688 VETERANS MEMORIAL DR 200
HATTIESBURG MS
39401-8246
US

V. Phone/Fax

Practice location:
  • Phone: 601-554-7402
  • Fax: 601-554-7488
Mailing address:
  • Phone: 601-554-7402
  • Fax: 601-554-7488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00079
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9103513
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: