Healthcare Provider Details

I. General information

NPI: 1225619018
Provider Name (Legal Business Name): JAMES AUSTIN CARPENTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 MIDDLETON RD STE 600
WINONA MS
38967-2021
US

IV. Provider business mailing address

375 HONEYCUTT RD
GORE SPRINGS MS
38929-9593
US

V. Phone/Fax

Practice location:
  • Phone: 662-283-1260
  • Fax:
Mailing address:
  • Phone: 662-582-8054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA7044
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: