Provider Demographics
NPI:1922548882
Name:CARTER, GREGORY BROCK (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:BROCK
Last Name:CARTER
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 1:7104 W ARBOR TRACE DR APT 311
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-3045
Mailing Address - Country:US
Mailing Address - Phone:865-456-0010
Mailing Address - Fax:
Practice Address - Street 1:10904 KINGSTON PIKE STE 101
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2952
Practice Address - Country:US
Practice Address - Phone:865-392-1388
Practice Address - Fax:865-392-1391
Is Sole Proprietor?:No
Enumeration Date:2017-02-26
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000003584363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant