Provider Demographics
NPI: | 1508856873 |
---|---|
Name: | NITZ, GRETCHEN JILLIAN (PA-C) |
Entity Type: | Individual |
Prefix: | MS |
First Name: | GRETCHEN |
Middle Name: | JILLIAN |
Last Name: | NITZ |
Suffix: | |
Gender: | F |
Credentials: | PA-C |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 151 FRANK L DIGGS DR |
Mailing Address - Street 2: | |
Mailing Address - City: | CLINTON |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37716-6953 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 865-647-3320 |
Mailing Address - Fax: | 865-647-3329 |
Practice Address - Street 1: | 919 E CENTRAL AVE STE 102 |
Practice Address - Street 2: | |
Practice Address - City: | LA FOLLETTE |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37766-2778 |
Practice Address - Country: | US |
Practice Address - Phone: | 423-907-1740 |
Practice Address - Fax: | 423-907-1743 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-10-26 |
Last Update Date: | 2022-03-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TN | 119 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | 3665540 | Medicaid | |
KY | P400020947 | Medicare PIN | |
KY | K024500 | Medicare PIN | |
TN | R60762 | Medicare UPIN | |
KY | 0644808 | Medicare PIN | |
P00841556 | Medicare PIN |