Healthcare Provider Details

I. General information

NPI: 1801862339
Provider Name (Legal Business Name): DONALD ALLEN BLACK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HIGHWAY 76
CLARKSVILLE TN
37043-8405
US

IV. Provider business mailing address

1000 HIGHWAY 76
CLARKSVILLE TN
37043-8405
US

V. Phone/Fax

Practice location:
  • Phone: 931-245-1150
  • Fax:
Mailing address:
  • Phone: 931-245-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA038
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: