Healthcare Provider Details

I. General information

NPI: 1295105278
Provider Name (Legal Business Name): CARLY STEGALL TUNBERG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARLY STEGALL YELVERTON

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N STATE ST
JACKSON MS
39202-2064
US

IV. Provider business mailing address

485 VIEWPOINTE WAY
CLINTON MS
39056-5962
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-1000
  • Fax:
Mailing address:
  • Phone: 601-720-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00257
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00257
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: