Healthcare Provider Details

I. General information

NPI: 1043276504
Provider Name (Legal Business Name): JULIE D BOGDAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 OZONA RD
PICAYUNE MS
39466-7819
US

IV. Provider business mailing address

341 OZONA RD
PICAYUNE MS
39466-7819
US

V. Phone/Fax

Practice location:
  • Phone: 601-749-1502
  • Fax:
Mailing address:
  • Phone: 601-749-1502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00227
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.A10440.RX
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: