Provider Demographics
NPI:1851034136
Name:SHERRILL, IRA SETH (PA-C)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:SETH
Last Name:SHERRILL
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 221
Mailing Address - Street 2:
Mailing Address - City:CRAB ORCHARD
Mailing Address - State:TN
Mailing Address - Zip Code:37723-0221
Mailing Address - Country:US
Mailing Address - Phone:931-252-1331
Mailing Address - Fax:
Practice Address - Street 1:100 LANTANA RD STE 202
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-1903
Practice Address - Country:US
Practice Address - Phone:931-252-1331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ076657Medicaid