Healthcare Provider Details

I. General information

NPI: 1538330485
Provider Name (Legal Business Name): CALEB SLOAN RAE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2008
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 POLK STREET
BENTON TN
37307
US

IV. Provider business mailing address

PO BOX 70
PALMER TN
37365-0000
US

V. Phone/Fax

Practice location:
  • Phone: 423-338-8995
  • Fax: 423-338-8996
Mailing address:
  • Phone: 931-779-4002
  • Fax: 931-779-4003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1558
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: