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General NPI Number Information
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NPI Number | 1689453524
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Entity Type | Individual
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Provider Name | PHILLIP MATTHEW EZELL FNP-BC, AGACNP-BC
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Gender | Male
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Dates
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Enumeration Date | 09/28/2023
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Last Update Date | 09/28/2023
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Provider Practice Location Address
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Address Line | 908 S GEORGE AVE
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City | PETAL
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State | MS
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Zip | 39465-2077
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Country | US
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Telephone | 601-544-7441
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Fax |
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Provider Business Mailing Address
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Address Line | 120 BROKEN ARROW TRL
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City | PETAL
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State | MS
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Zip | 39465-8952
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Country | US
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Telephone | 601-466-8121
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number | 905839
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 905839
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License Number State | MS
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