Healthcare Provider Details

I. General information

NPI: 1104059765
Provider Name (Legal Business Name): PRESTON PARKER EMBREY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2009
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 E COURT AVE
SELMER TN
38375-2304
US

IV. Provider business mailing address

257 BANCORP SOUTH PKWY # TN38305
JACKSON TN
38305-7582
US

V. Phone/Fax

Practice location:
  • Phone: 731-541-9490
  • Fax:
Mailing address:
  • Phone: 731-660-8759
  • Fax: 731-660-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1768
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1768
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: