Provider Demographics
NPI:1003404831
Name:FOSTER, GARY CLINTON (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:CLINTON
Last Name:FOSTER
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 STELLA RUTH RD
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-8503
Mailing Address - Country:US
Mailing Address - Phone:731-796-5900
Mailing Address - Fax:
Practice Address - Street 1:551 STELLA RUTH RD
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-8503
Practice Address - Country:US
Practice Address - Phone:731-796-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28915363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care