Provider Demographics
NPI:1326056714
Name:COSS, PACITA R (MD)
Entity Type:Individual
Prefix:
First Name:PACITA
Middle Name:R
Last Name:COSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-8700
Mailing Address - Fax:601-582-5461
Practice Address - Street 1:222 S 27TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7165
Practice Address - Country:US
Practice Address - Phone:601-450-3030
Practice Address - Fax:601-450-3031
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13634207Q00000X
AZ5754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112217Medicaid
MS1558931OtherAMERICAN ADMIN GROUP
MS512I080292OtherMEIDARE PTAN (PROVIDER TRANSACTION ACCESS NUMBER)
080047101OtherRAILROAD MEDICARE
MS00112217Medicaid
E47676Medicare UPIN