Healthcare Provider Details

I. General information

NPI: 1427101294
Provider Name (Legal Business Name): UPA PLLC DIV OF PULMONARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 08/22/2020
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: 601-815-8989
  • Fax:
Mailing address:
  • Phone: 601-815-8989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State

VIII. Authorized Official

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