Provider Demographics
NPI:1730302191
Name:COVINGTON, CALLIE COURTNEY (PA-C)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:COURTNEY
Last Name:COVINGTON
Suffix:
Gender:F
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 1:1325 WOLF PARK DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1759
Mailing Address - Country:US
Mailing Address - Phone:901-252-3411
Mailing Address - Fax:901-763-4305
Practice Address - Street 1:1325 WOLF PARK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1759
Practice Address - Country:US
Practice Address - Phone:901-252-3400
Practice Address - Fax:901-763-4305
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00089363A00000X
TN2120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I970013OtherMEDICARE PROVIDER TRANSACTION ACCESSUE NUMBER