Healthcare Provider Details

I. General information

NPI: 1922585967
Provider Name (Legal Business Name): WILLIAM MATTHEW CLIBURN MSN, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 E WOODROW WILSON AVE
JACKSON MS
39216-5112
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 800-223-6672
  • Fax:
Mailing address:
  • Phone: 601-984-5706
  • Fax: 601-984-5733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902747
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: