Healthcare Provider Details

I. General information

NPI: 1871215970
Provider Name (Legal Business Name): FREDERICK BARNETT CARLTON III FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 AZALEA DR
OXFORD MS
38655-7900
US

IV. Provider business mailing address

53 SHELIA DR
OXFORD MS
38655-5609
US

V. Phone/Fax

Practice location:
  • Phone: 662-234-0332
  • Fax:
Mailing address:
  • Phone: 662-832-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905555
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: