Basic Information
Provider Information | |||||||||
NPI: | 1548679244 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HALL | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | VINCENT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1301 S SHIVERS ST | ||||||||
Address2: |   | ||||||||
City: | POPLARVILLE | ||||||||
State: | MS | ||||||||
PostalCode: | 394703225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6012700038 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 64167 HIGHWAY 41 STE C | ||||||||
Address2: |   | ||||||||
City: | PEARL RIVER | ||||||||
State: | LA | ||||||||
PostalCode: | 704523638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9852509700 | ||||||||
FaxNumber: | 8448995208 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2014 | ||||||||
LastUpdateDate: | 09/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R889798 | MS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP08096 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 2409964 | 05 | LA |   | MEDICAID |