Provider Demographics
NPI:1811458565
Name:PHYSICIAN ASSOCIATE RESOURCES, PLC
Entity type:Organization
Organization Name:PHYSICIAN ASSOCIATE RESOURCES, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:HAMM
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:865-635-8389
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:865-635-8390
Practice Address - Street 1:1559 HIGHLAND PARK DRIVE
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772
Practice Address - Country:US
Practice Address - Phone:865-748-5057
Practice Address - Fax:865-635-8390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-26
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3669684Medicaid
TNPA0000000203OtherSTATE OF TN