Healthcare Provider Details

I. General information

NPI: 1710639356
Provider Name (Legal Business Name): TREVOR LEE TATUM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15232 GREENFIELD DR
ATHENS AL
35613-2897
US

IV. Provider business mailing address

525 WILD RIDGE CIR
PELHAM AL
35124-2528
US

V. Phone/Fax

Practice location:
  • Phone: 256-233-1650
  • Fax: 256-233-7244
Mailing address:
  • Phone: 706-594-8563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1909
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: