Provider Demographics
NPI:1568069201
Name:HILLIARD, WARREN
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:
Last Name:HILLIARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7625 HWY 64
Mailing Address - Street 2:107
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38133
Mailing Address - Country:US
Mailing Address - Phone:901-213-1110
Mailing Address - Fax:901-213-1767
Practice Address - Street 1:1030 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000037467207Q00000X
TN27917363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine