Provider Demographics
NPI:1750590923
Name:DERMATOLOGY ASSOCIATES LLC
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:BOOHER
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:731-661-0061
Mailing Address - Street 1:2817 N HIGHLAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1789
Mailing Address - Country:US
Mailing Address - Phone:731-661-0061
Mailing Address - Fax:731-661-9107
Practice Address - Street 1:2817 N HIGHLAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1789
Practice Address - Country:US
Practice Address - Phone:731-661-0061
Practice Address - Fax:731-661-9107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN 000 000 8039363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7587201OtherAETNA
TN3370114Medicaid
TN4165097OtherBLUE CROSS BLUE SHIELD
TN3370114Medicare PIN