Provider Demographics
NPI:1649270844
Name:HAMM, RUDY GARY (PA-C)
Entity type:Individual
Prefix:MR
First Name:RUDY
Middle Name:GARY
Last Name:HAMM
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 1:1559 HIGHLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-6237
Mailing Address - Country:US
Mailing Address - Phone:865-635-8389
Mailing Address - Fax:656-358-3908
Practice Address - Street 1:1559 HIGHLAND PARK DR
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-6237
Practice Address - Country:US
Practice Address - Phone:865-635-8389
Practice Address - Fax:865-635-8390
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000000203TN363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3669684Medicaid