Healthcare Provider Details

I. General information

NPI: 1235326059
Provider Name (Legal Business Name): MARK A. WHITEHEAD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 TROTWOOD AVE. STE 108
COLUMBIA TN
38401
US

IV. Provider business mailing address

326 N LOCUST AVE STE B
LAWRENCEBURG TN
38464-3516
US

V. Phone/Fax

Practice location:
  • Phone: 931-388-8965
  • Fax: 931-840-8520
Mailing address:
  • Phone: 931-762-9797
  • Fax: 931-762-9798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1531
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA0000001531
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: