Healthcare Provider Details

I. General information

NPI: 1285853002
Provider Name (Legal Business Name): TRISTEN ANNE HARRIS MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DEPARTMENT OF OTOLARYNGOLOGY
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST DEPARTMENT OF OTOLARYNGOLOGY
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5160
  • Fax: 601-815-6985
Mailing address:
  • Phone: 601-984-5160
  • Fax: 601-815-6985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 0038
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: