Provider Demographics
NPI:1609105196
Name:TULLOS, JOSEPH BYRON (FNP)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:BYRON
Last Name:TULLOS
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1100 HIGHWAY 16 E
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-4222
Practice Address - Country:US
Practice Address - Phone:601-267-1470
Practice Address - Fax:601-267-1469
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866137363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02236231Medicaid
MS02236231Medicaid
TX8EM377Medicare PIN