Basic Information
| Provider Information | |||||||||
| NPI: | 1598043143 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GASPARD | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012005955 | ||||||||
| FaxNumber: | 6012005943 | ||||||||
| Practice Location | |||||||||
| Address1: | 971 LAKELAND DR STE 1250 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012005955 | ||||||||
| FaxNumber: | 6012005939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2011 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 31518 | AL | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 21587 | MS | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2189662 | 05 | LA | MEDICAID | 04383309 | 05 | MS | MEDICAID |