Healthcare Provider Details

I. General information

NPI: 1689453524
Provider Name (Legal Business Name): PHILLIP MATTHEW EZELL FNP-BC, AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2023
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 S GEORGE AVE
PETAL MS
39465-2077
US

IV. Provider business mailing address

670 WEATHERSBY RD STE 140
HATTIESBURG MS
39402-9586
US

V. Phone/Fax

Practice location:
  • Phone: 601-544-7441
  • Fax:
Mailing address:
  • Phone: 601-318-0669
  • Fax: 601-994-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number905839
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number905839
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: