Basic Information
| Provider Information | |||||||||
| NPI: | 1316941040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOUNT | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012273255 | ||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 641 RB WILSON DR STE G | ||||||||
| Address2: | |||||||||
| City: | HUNTINGDON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383441734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319867400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 02/27/2019 | ||||||||
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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 | 1075 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3380640 | 01 | TN | GROUP MEDICARE NUMBER | OTHER | 3380640 | 01 | TN | GROUP MEDICAID NUMBER | OTHER |