Healthcare Provider Details

I. General information

NPI: 1770216863
Provider Name (Legal Business Name): KASON JAMES FARK PARAMEDIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

1011 HAGGARD DR
CLARKSVILLE TN
37043-5640
US

V. Phone/Fax

Practice location:
  • Phone: 270-412-8453
  • Fax:
Mailing address:
  • Phone: 812-774-2069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number212128
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: