Healthcare Provider Details

I. General information

NPI: 1548628522
Provider Name (Legal Business Name): WESLEY ESTOCK PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4934
US

IV. Provider business mailing address

830 S GLOSTER ST
TUPELO MS
38801-4934
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3000
  • Fax:
Mailing address:
  • Phone: 662-377-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTPA0029
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: