Healthcare Provider Details

I. General information

NPI: 1497019707
Provider Name (Legal Business Name): MEDICAL ARTS PLAZA, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 HIGHWAY 28 SUITE 100
JASPER TN
37347-3695
US

IV. Provider business mailing address

980 HIGHWAY 28 SUITE 100
JASPER TN
37347-3695
US

V. Phone/Fax

Practice location:
  • Phone: 423-942-1602
  • Fax: 423-942-1265
Mailing address:
  • Phone: 423-942-1602
  • Fax: 423-942-1265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7170
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25036
License Number StateTN

VIII. Authorized Official

Name: DR. SCOTT EUGENE DESJARLAIS
Title or Position: REGISTERED AGENT
Credential: M.D.
Phone: 423-942-1602