Provider Demographics
NPI:1295562106
Name:DETTORE, AVA ROSE (PA)
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:ROSE
Last Name:DETTORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4104 DAYTON BLVD
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:TN
Mailing Address - Zip Code:37415-7155
Mailing Address - Country:US
Mailing Address - Phone:423-499-7710
Mailing Address - Fax:
Practice Address - Street 1:4104 DAYTON BLVD
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:TN
Practice Address - Zip Code:37415-7155
Practice Address - Country:US
Practice Address - Phone:423-499-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant