Provider Demographics
NPI:1023028925
Name:PURVIANCE, HOLLIS LANGSTON III (CFNP)
Entity Type:Individual
Prefix:MR
First Name:HOLLIS
Middle Name:LANGSTON
Last Name:PURVIANCE
Suffix:III
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:CBO - SUITE 4200
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-496-9794
Mailing Address - Fax:601-815-0434
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:UNIVERSITY ORTHOPEDIC ASSOCIATES PLLC
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-1000
Practice Address - Fax:601-984-6533
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR859975363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS8425307Medicaid
MS512G700003OtherUNIVERSITY PHYSICIANS
MSP01194846OtherRR MEDICARE PTAN
MS08425307Medicaid
MSP00618110OtherRR PTAN
MS302I505883Medicare PIN
MS512G700003OtherUNIVERSITY PHYSICIANS