MEDICARE: MR. ISAAC NATHAN O'DELL PA

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	363AM0700X	Medical Physician Assistant	PA0000001330	TN
2	363AS0400X	Surgical Physician Assistant	PA0000001330	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4126669	OTHER	TN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821035908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ISAAC NATHAN O'DELL PA

Provider Business Mailing Address
First Line	:	PO BOX 9150
Second Line	:
City	:	PADUCAH
State	:	KY
Zip	:	42002-9150
Country	:	US
Telephone Number	:	270-744-9600
Fax Number	:	270-744-0834

Provider Business Practice Location Address
First Line	:	701 MED TECH PKWY
Second Line	:	SUITE 300
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-2365
Country	:	US
Telephone Number	:	423-232-8301
Fax Number	:	423-232-8304

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

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	12/10/2009

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