Healthcare Provider Details

I. General information

NPI: 1689113250
Provider Name (Legal Business Name): BRENNAN FOSTER VAUGHN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 RAYMOND RD
JACKSON MS
39204-4358
US

IV. Provider business mailing address

1420 RAYMOND RD
JACKSON MS
39204-4358
US

V. Phone/Fax

Practice location:
  • Phone: 601-387-3400
  • Fax:
Mailing address:
  • Phone: 601-387-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberPA00323
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00323
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: