Provider Demographics
NPI:1760429740
Name:PROVANCE, PAUL THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:THOMAS
Last Name:PROVANCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4000
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-4000
Mailing Address - Country:US
Mailing Address - Phone:423-926-1171
Mailing Address - Fax:
Practice Address - Street 1:JAMES H QUILLEN VA MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684-4000
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.086268207R00000X
TNMD41434207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3825653Medicaid
OH2571293Medicaid
TN3825653Medicaid
TN3700592Medicare UPIN
TN3825653Medicare UPIN
OH2571293Medicaid