Basic Information
| Provider Information | |||||||||
| NPI: | 1235326059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITEHEAD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 326 N LOCUST AVE | ||||||||
| Address2: | STE B | ||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384643516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317629797 | ||||||||
| FaxNumber: | 9317629798 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 TROTWOOD AVE. | ||||||||
| Address2: | STE 108 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313888965 | ||||||||
| FaxNumber: | 9318408520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2007 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1531 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208000000X | PA0000001531 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1501347 | 05 | TN | MEDICAID |