Provider Demographics
NPI:1376506741
Name:SOUTH, TIMOTHY M (FNP)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:M
Last Name:SOUTH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 HIGHWAY 12 W
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3209
Mailing Address - Country:US
Mailing Address - Phone:662-289-1800
Mailing Address - Fax:662-289-2486
Practice Address - Street 1:332 HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3209
Practice Address - Country:US
Practice Address - Phone:662-289-1800
Practice Address - Fax:662-289-2486
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR701483363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114061Medicaid
MS00114061Medicaid
MSR34729Medicare UPIN