Provider Demographics
NPI:1689453524
Name:EZELL, PHILLIP MATTHEW (FNP-BC, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:MATTHEW
Last Name:EZELL
Suffix:
Gender:M
Credentials:FNP-BC, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BROKEN ARROW TRL
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-8952
Mailing Address - Country:US
Mailing Address - Phone:601-466-8121
Mailing Address - Fax:
Practice Address - Street 1:908 S GEORGE AVE
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2077
Practice Address - Country:US
Practice Address - Phone:601-544-7441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905839207RC0200X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine