Provider Demographics
NPI:1437620085
Name:GATLIN, EDWARD N (ETC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:N
Last Name:GATLIN
Suffix:
Gender:M
Credentials:ETC
Other - Prefix:MR
Other - First Name:EDWARD
Other - Middle Name:N
Other - Last Name:GATLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:E & J TRANSPORTATION
Mailing Address - Street 1:20 OTIS LN
Mailing Address - Street 2:
Mailing Address - City:FOXWORTH
Mailing Address - State:MS
Mailing Address - Zip Code:39483-3102
Mailing Address - Country:US
Mailing Address - Phone:601-467-0848
Mailing Address - Fax:
Practice Address - Street 1:20 OTIS LN
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483-3102
Practice Address - Country:US
Practice Address - Phone:601-467-0848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS801615243172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS801615243OtherDRIVER LICENSE
MS832-374-5638OtherTAX EIN NUMBER