Basic Information
| Provider Information | |||||||||
| NPI: | 1568875151 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | OVERSTREET | ||||||||
| FirstName: | BRIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845571 | ||||||||
| FaxNumber: | 6019845583 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845571 | ||||||||
| FaxNumber: | 6019845583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2014 | ||||||||
| LastUpdateDate: | 01/16/2017 | ||||||||
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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 | 363LP2300X | R878670 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LA2100X | R878670 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 05873296 | 05 | MS | MEDICAID | 2408143 | 05 | LA | MEDICAID |