Healthcare Provider Details

I. General information

NPI: 1558340026
Provider Name (Legal Business Name): MARK WILLIAM TRAUGH P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 W FOREST AVE
JACKSON TN
38301-3901
US

IV. Provider business mailing address

1804 HIGHWAY 45 BYP SUITE 604
JACKSON TN
38305-4436
US

V. Phone/Fax

Practice location:
  • Phone: 731-425-6280
  • Fax: 731-425-4922
Mailing address:
  • Phone: 731-660-8759
  • Fax: 731-660-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA558
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: