Provider Demographics
NPI:1629072160
Name:SNOWDEN, JOHN DOUGLAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DOUGLAS
Last Name:SNOWDEN
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 1:303 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1203
Mailing Address - Country:US
Mailing Address - Phone:618-847-8243
Mailing Address - Fax:
Practice Address - Street 1:1861 MAIN ST
Practice Address - Street 2:
Practice Address - City:SNEEDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37869-3645
Practice Address - Country:US
Practice Address - Phone:423-733-2131
Practice Address - Fax:423-733-1055
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4176065OtherBCBST
TN36672101Medicaid
TN36672101Medicaid
36672102Medicare PIN