Healthcare Provider Details

I. General information

NPI: 1023028925
Provider Name (Legal Business Name): HOLLIS LANGSTON PURVIANCE III CFNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST UNIVERSITY ORTHOPEDIC ASSOCIATES PLLC
JACKSON MS
39216
US

IV. Provider business mailing address

2500 N STATE ST CBO - SUITE 4200
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1000
  • Fax: 601-984-6533
Mailing address:
  • Phone: 601-496-9794
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR859975
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: