MEDICARE: GINA RAWLS PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	3869	TN

General Provider Information

NPI Number	:	1578832275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA RAWLS PTA

Provider Business Mailing Address
First Line	:	5525 CREOLE WAY
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-8806
Country	:	US
Telephone Number	:	615-516-2479
Fax Number	:

Provider Business Practice Location Address
First Line	:	5525 CREOLE WAY
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-8806
Country	:	US
Telephone Number	:	615-516-2479
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2011
Last Update Date	:	12/26/2011

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