Provider Demographics
NPI:1629752514
Name:CLONCH, TAVIS D (PA)
Entity Type:Individual
Prefix:
First Name:TAVIS
Middle Name:D
Last Name:CLONCH
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Gender:M
Credentials:PA
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Mailing Address - Street 1:1 MEDICAL PARK BLVD STE 300E
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7497
Mailing Address - Country:US
Mailing Address - Phone:423-844-6450
Mailing Address - Fax:423-844-6499
Practice Address - Street 1:1 MEDICAL PARK BLVD STE 300E
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7497
Practice Address - Country:US
Practice Address - Phone:423-844-6450
Practice Address - Fax:423-844-6499
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant