Provider Demographics
NPI:1538489539
Name:HALTOM, GREGORY WAYNE (LSA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:WAYNE
Last Name:HALTOM
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 RYAN AVE
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-6621
Mailing Address - Country:US
Mailing Address - Phone:615-230-1714
Mailing Address - Fax:
Practice Address - Street 1:509 RYAN AVE
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-6621
Practice Address - Country:US
Practice Address - Phone:615-230-1714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00211246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist