Healthcare Provider Details

I. General information

NPI: 1891489365
Provider Name (Legal Business Name): JOSHUA BO HINTON CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 10/04/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 NORTHVILLAGE LN
PETAL MS
39465-3513
US

IV. Provider business mailing address

109 NORTHVILLAGE LN
PETAL MS
39465-3513
US

V. Phone/Fax

Practice location:
  • Phone: 601-319-1208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number210205
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: