Provider Demographics
NPI:1548241359
Name:BREEDING, BYRON MICHAEL (PA C)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:MICHAEL
Last Name:BREEDING
Suffix:
Gender:M
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 1:144 EDENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3827
Mailing Address - Country:US
Mailing Address - Phone:731-256-1466
Mailing Address - Fax:
Practice Address - Street 1:144 EDENWOOD DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3827
Practice Address - Country:US
Practice Address - Phone:731-256-1466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001272363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00292468OtherRAILROAD MEDICARE
TN3701995Medicaid
P00292468OtherRAILROAD MEDICARE
TN3663835Medicare ID - Type Unspecified