Provider Demographics
NPI:1477599892
Name:LANDRY, PAUL B III (PAC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:B
Last Name:LANDRY
Suffix:III
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6008
Mailing Address - Country:US
Mailing Address - Phone:423-929-7393
Mailing Address - Fax:423-929-0872
Practice Address - Street 1:310 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6008
Practice Address - Country:US
Practice Address - Phone:423-929-7393
Practice Address - Fax:423-929-0872
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1603363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1477599892Medicaid
TN1506078Medicaid
TNTN01 UWOtherJOHN DEERE
TN4190518OtherBC/BS
KY7100095460Medicaid
TNP00686005OtherRAILROAD MEDICARE
TN1506078Medicaid