Healthcare Provider Details

I. General information

NPI: 1164920930
Provider Name (Legal Business Name): CATHERINE SUPPLE BRYANT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CATHERINE ELLEN SUPPLE

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 01/26/2018
Certification Date:
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

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

V. Phone/Fax

Practice location:
  • Phone: 601-944-1781
  • Fax: 601-353-0439
Mailing address:
  • Phone: 601-944-1781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: