Provider Demographics
NPI:1437499084
Name:LIPSCOMB, MICHAEL LOUIS (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LOUIS
Last Name:LIPSCOMB
Suffix:
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 1:6025 WALNUT GROVE RD STE 508
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2125
Mailing Address - Country:US
Mailing Address - Phone:901-767-5864
Mailing Address - Fax:901-767-6591
Practice Address - Street 1:6025 WALNUT GROVE RD STE 508
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2125
Practice Address - Country:US
Practice Address - Phone:901-767-5864
Practice Address - Fax:901-767-6591
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1533087Medicaid