Provider Demographics
NPI:1760711469
Name:MAUNEY, JIMMY RUSSELL (PA-C)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:RUSSELL
Last Name:MAUNEY
Suffix:
Gender:M
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:PO BOX 306556
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6556
Mailing Address - Country:US
Mailing Address - Phone:615-329-2294
Mailing Address - Fax:615-695-1494
Practice Address - Street 1:141 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5088
Practice Address - Country:US
Practice Address - Phone:931-552-4340
Practice Address - Fax:931-552-0999
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2008363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ006557Medicaid