Provider Demographics
NPI:1790827335
Name:DEBEN, FREDERICK JOSEPH JR (NP)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:JOSEPH
Last Name:DEBEN
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466
Mailing Address - Country:US
Mailing Address - Phone:228-324-6406
Mailing Address - Fax:
Practice Address - Street 1:422 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466
Practice Address - Country:US
Practice Address - Phone:601-798-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR768485363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01930561Medicaid
MS01930561Medicaid
MS302I500756Medicare PIN