Provider Demographics
NPI:1740330315
Name:LAUF, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LAUF
Suffix:
Gender:F
Credentials:
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 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2093
Mailing Address - Fax:423-857-2012
Practice Address - Street 1:240 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 3800
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7346
Practice Address - Country:US
Practice Address - Phone:423-990-2466
Practice Address - Fax:423-990-2407
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA 01437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicare PIN
0281780001Medicare PIN
0281780003Medicare PIN