Basic Information
| Provider Information | |||||||||
| NPI: | 1871935189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARR | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | EVAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015795463 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 6941 HIGHWAY 11 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CARRIERE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394267793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017943714 | ||||||||
| FaxNumber: | 6017493776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2013 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R856733 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 06437250 | 05 | MS | MEDICAID |