Healthcare Provider Details

I. General information

NPI: 1346351194
Provider Name (Legal Business Name): STEVEN HENRY PACK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 CADET CT
LEBANON TN
37087-2649
US

IV. Provider business mailing address

706 CADET CT
LEBANON TN
37087-2649
US

V. Phone/Fax

Practice location:
  • Phone: 615-449-2472
  • Fax: 615-449-4709
Mailing address:
  • Phone: 615-449-2472
  • Fax: 615-449-4709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA626
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: