Healthcare Provider Details

I. General information

NPI: 1336871904
Provider Name (Legal Business Name): CHRIS EDENS MARCELLUS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 MONROE AVE
MEMPHIS TN
38104-3634
US

IV. Provider business mailing address

PO BOX 22403
BELFAST ME
04915-4476
US

V. Phone/Fax

Practice location:
  • Phone: 901-296-9400
  • Fax: 901-272-0820
Mailing address:
  • Phone: 888-402-7256
  • Fax: 888-902-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5687
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: