Provider Demographics
NPI:1013905272
Name:WEATHERSBY, PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:WEATHERSBY
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 1:202 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-3009
Mailing Address - Country:US
Mailing Address - Phone:662-453-0646
Mailing Address - Fax:662-455-6842
Practice Address - Street 1:202 W PARK AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-3009
Practice Address - Country:US
Practice Address - Phone:662-453-0646
Practice Address - Fax:662-455-6842
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08062174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122953Medicaid
MS00122953Medicaid