Healthcare Provider Details

I. General information

NPI: 1922711944
Provider Name (Legal Business Name): MRS. CAROLINE IRBY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 N STATE ST STE 502
JACKSON MS
39202-2414
US

IV. Provider business mailing address

117 PALIN DR
MADISON MS
39110-6959
US

V. Phone/Fax

Practice location:
  • Phone: 601-944-1781
  • Fax:
Mailing address:
  • Phone: 601-863-9441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberPA00692
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: