Individual
MARISSA HUMPHREY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 984-5931
Mailing address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 984-5931
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
23357
MS
207L00000X
Anesthesiology Physician
Primary
MD214825
OR
207R00000X
Internal Medicine Physician
253540
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
06457521
—
MS
01
—
P01454807
RAILROAD MEDICARE PTAN
MS
Enumeration date
06/15/2009
Last updated
09/06/2024
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