Provider Demographics
NPI:1215403712
Name:HARMON, RONALD MACK
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:MACK
Last Name:HARMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 GREYSTONE SQ
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3580
Mailing Address - Country:US
Mailing Address - Phone:731-300-2001
Mailing Address - Fax:731-240-8095
Practice Address - Street 1:1004 GREYSTONE SQ
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3580
Practice Address - Country:US
Practice Address - Phone:731-664-1773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25062363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ047667Medicaid