Healthcare Provider Details

I. General information

NPI: 1972023943
Provider Name (Legal Business Name): THOMAS CLAY CARRUTH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7691 POPLAR AVE
GERMANTOWN TN
38138-3904
US

IV. Provider business mailing address

3932 PHILWOOD AVE
MEMPHIS TN
38122-3879
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-6970
  • Fax:
Mailing address:
  • Phone: 731-220-1091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22776
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: