Healthcare Provider Details

I. General information

NPI: 1609308246
Provider Name (Legal Business Name): ROBERT BRYAN WHISENHUNT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 205
TULLAHOMA TN
37388-0205
US

IV. Provider business mailing address

PO BOX 205
TULLAHOMA TN
37388-0205
US

V. Phone/Fax

Practice location:
  • Phone: 931-841-5678
  • Fax:
Mailing address:
  • Phone: 931-841-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA304
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: