Provider Demographics
NPI:1073020400
Name:BROWN, TOMMY LEE JR (PA)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:LEE
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BAYNE-JONES ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:1585 THIRD ST
Mailing Address - City:FT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459
Mailing Address - Country:US
Mailing Address - Phone:808-295-4601
Mailing Address - Fax:
Practice Address - Street 1:BAYNE-JONES ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:1585 THIRD ST
Practice Address - City:FT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459
Practice Address - Country:US
Practice Address - Phone:808-295-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2022-08-03
Deactivation Date:2021-05-25
Deactivation Code:
Reactivation Date:2021-06-18
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
GA1198850363A00000X
GAM5024678146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic