Healthcare Provider Details

I. General information

NPI: 1194517714
Provider Name (Legal Business Name): FNU SAMRA MARIYAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET DEPARTMENT OF PATHOLOGY
JACKSON MS
39216
US

IV. Provider business mailing address

2500 NORTH STATE STREET DEPARTMENT OF PATHOLOGY
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1879
  • Fax:
Mailing address:
  • Phone: 601-984-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberT-5961
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: