Healthcare Provider Details

I. General information

NPI: 1730945775
Provider Name (Legal Business Name): TYLER BRANSCUM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 HIGHWAY 411
MADISONVILLE TN
37354-4417
US

IV. Provider business mailing address

PO BOX 808
KINGSTON TN
37763-0808
US

V. Phone/Fax

Practice location:
  • Phone: 423-442-2121
  • Fax: 423-545-9556
Mailing address:
  • Phone: 423-442-2121
  • Fax: 423-545-9556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6050
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: