Basic Information
| Provider Information | |||||||||
| NPI: | 1518304229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYATT ASHMEAD | ||||||||
| FirstName: | JOSEPHINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019841540 | ||||||||
| FaxNumber: | 6019841531 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019841540 | ||||||||
| FaxNumber: | 6019841531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2013 | ||||||||
| LastUpdateDate: | 12/02/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZN0500X | 17447 | MS | N | Allopathic & Osteopathic Physicians | Pathology | Neuropathology | 207ZP0101X | 17447 | MS | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0213X | 17447 | MS | Y | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00122583 | 05 | MS | MEDICAID |