Healthcare Provider Details

I. General information

NPI: 1326816984
Provider Name (Legal Business Name): EDWARD ZACHARY WARREN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N STATE ST
JACKSON MS
39202-2064
US

IV. Provider business mailing address

1408 E PEACE ST
CANTON MS
39046-4957
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-1700
  • Fax:
Mailing address:
  • Phone: 769-232-9094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF01240409
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: