Provider Demographics
NPI:1811075088
Name:BROCK, RONDAL KEITH (PAC)
Entity type:Individual
Prefix:
First Name:RONDAL
Middle Name:KEITH
Last Name:BROCK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1037 OLD JACKSOBORO ROAD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37724-4444
Mailing Address - Country:US
Mailing Address - Phone:423-869-9980
Mailing Address - Fax:423-526-2804
Practice Address - Street 1:TAZEWELL MEDICAL CLINIC 1442 NORTH BROAD STREET
Practice Address - Street 2:SUITE 7
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879
Practice Address - Country:US
Practice Address - Phone:423-626-6145
Practice Address - Fax:423-526-2804
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNR83308Medicare UPIN