Basic Information
Provider Information | |||||||||
NPI: | 1689113250 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAUGHN | ||||||||
FirstName: | BRENNAN | ||||||||
MiddleName: | FOSTER | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4204 CLAY ST | ||||||||
Address2: |   | ||||||||
City: | VICKSBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 391833438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6016197717 | ||||||||
FaxNumber: | 6016197782 | ||||||||
Practice Location | |||||||||
Address1: | 4204 CLAY ST | ||||||||
Address2: |   | ||||||||
City: | VICKSBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 391833438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6016197717 | ||||||||
FaxNumber: | 6016197782 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2017 | ||||||||
LastUpdateDate: | 02/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | PA00323 | MS | N |   | Other Service Providers | Military Health Care Provider |   | 363A00000X | PA00323 | MS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.