Provider Demographics
NPI:1740791847
Name:CHILDRESS, BRIAN BLAKE (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:BLAKE
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-422-0213
Mailing Address - Fax:731-660-8319
Practice Address - Street 1:87 MURRAY GUARD DR STE B
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3775
Practice Address - Country:US
Practice Address - Phone:731-422-0213
Practice Address - Fax:731-660-8319
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA3467363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant