Healthcare Provider Details

I. General information

NPI: 1326593336
Provider Name (Legal Business Name): ROBERT IRA VAIL F.N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 W BANKHEAD ST
NEW ALBANY MS
38652-3319
US

IV. Provider business mailing address

474 W BANKHEAD ST
NEW ALBANY MS
38652-3319
US

V. Phone/Fax

Practice location:
  • Phone: 662-534-7777
  • Fax: 662-534-3050
Mailing address:
  • Phone: 662-534-7777
  • Fax: 662-534-3050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901716
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: