Provider Demographics
NPI:1962682765
Name:MOSLEY, MISTY SHEA (MD)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:SHEA
Last Name:MOSLEY
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 1:844 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4904
Mailing Address - Country:US
Mailing Address - Phone:662-377-5400
Mailing Address - Fax:662-377-5415
Practice Address - Street 1:844 S MADISON ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4904
Practice Address - Country:US
Practice Address - Phone:662-377-5400
Practice Address - Fax:662-377-5415
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-1852207Q00000X
MS20141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I080154Medicare PIN
MS500950YWZ1Medicare PIN