1598250359 NPI number — PATRICIA LYNN WHARTON LADAC 2, NCAC 1

Table of content: PATRICIA LYNN WHARTON LADAC 2, NCAC 1 (NPI 1598250359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598250359 NPI number — PATRICIA LYNN WHARTON LADAC 2, NCAC 1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHARTON
Provider First Name:
PATRICIA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LADAC 2, NCAC 1
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOWLER
Provider Other First Name:
PATRICIA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LADAC 2
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598250359
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
547 W LAMAR ALEXANDER PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37801-4760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-518-2433
Provider Business Mailing Address Fax Number:
865-318-9025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
547 W LAMAR ALEXANDER PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37801-4760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-518-2433
Provider Business Practice Location Address Fax Number:
865-318-9025
Provider Enumeration Date:
06/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1210 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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