Provider Demographics
NPI:1689714271
Name:NOWLIN, JOHNNY S (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:S
Last Name:NOWLIN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3419 TANYARD HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CULLEOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38451-2343
Mailing Address - Country:US
Mailing Address - Phone:931-987-2822
Mailing Address - Fax:
Practice Address - Street 1:1224 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4802
Practice Address - Country:US
Practice Address - Phone:931-380-4017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000089363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36630821Medicaid
TN1505420Medicaid
TN3710089Medicaid
TN3732438Medicaid
4186410OtherBCBST
36630821Medicare PIN
3710089Medicare PIN
4186410OtherBCBST
36630822Medicare PIN
TN3663082Medicare UPIN
TN3732438Medicaid