Provider Demographics
NPI:1154494383
Name:BENNETT, TAMARA L (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:979 E 3RD ST STE A550
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2136
Mailing Address - Country:US
Mailing Address - Phone:423-778-8224
Mailing Address - Fax:423-778-3913
Practice Address - Street 1:979 E 3RD ST STE A550
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2136
Practice Address - Country:US
Practice Address - Phone:423-778-8224
Practice Address - Fax:423-778-3913
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00574025Medicare PIN