Provider Demographics
NPI:1255752069
Name:MORGAN, CARL RANDOLPH III
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:RANDOLPH
Last Name:MORGAN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:280 VIRGINIA AVE NE
Practice Address - Street 2:SUITE 107
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1538
Practice Address - Country:US
Practice Address - Phone:276-679-5390
Practice Address - Fax:276-679-5395
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255752069Medicaid
TNQ003803Medicaid
TNQ003803Medicaid
VAVVC636BMedicare PIN
VA1255752069Medicaid