Provider Demographics
NPI:1114951258
Name:MORTON, MARY N (PAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:N
Last Name:MORTON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 21ST AVE S
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-4354
Mailing Address - Country:US
Mailing Address - Phone:615-269-0652
Mailing Address - Fax:615-269-0135
Practice Address - Street 1:651 DUNLOP LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5015
Practice Address - Country:US
Practice Address - Phone:931-502-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3717550Medicaid
TN103I972435Medicare PIN
TN3717550Medicaid
TN36630001Medicare PIN
Q30651Medicare UPIN