Provider Demographics
NPI:1831373810
Name:DORTCH-FARMER, KRISTEN R (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:R
Last Name:DORTCH-FARMER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 GUNSON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37050-4369
Mailing Address - Country:US
Mailing Address - Phone:931-220-6258
Mailing Address - Fax:
Practice Address - Street 1:1469 TINY TOWN RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-7202
Practice Address - Country:US
Practice Address - Phone:931-343-3347
Practice Address - Fax:931-905-7008
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1433363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1517181Medicaid
TN10397I4847Medicare PIN