Healthcare Provider Details

I. General information

NPI: 1205953809
Provider Name (Legal Business Name): UPA PLLC ADOLESCENT MED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5236
  • Fax:
Mailing address:
  • Phone: 601-984-5236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: OWEN B EVANS
Title or Position: MANAGING EMPLOYEE
Credential: M.D.
Phone: 601-984-5214