Provider Demographics
NPI:1912309725
Name:MOHAMMAD, SADRIL
Entity Type:Individual
Prefix:
First Name:SADRIL
Middle Name:
Last Name:MOHAMMAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1754 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37879-4365
Mailing Address - Country:US
Mailing Address - Phone:865-385-6232
Mailing Address - Fax:
Practice Address - Street 1:1754 N BROAD ST
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879-4365
Practice Address - Country:US
Practice Address - Phone:865-385-6232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant