Healthcare Provider Details

I. General information

NPI: 1255752069
Provider Name (Legal Business Name): CARL RANDOLPH MORGAN III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2013
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 VIRGINIA AVE NE SUITE 107
NORTON VA
24273-1538
US

IV. Provider business mailing address

105 W STONE DR SUITE 6A
KINGSPORT TN
37660-3365
US

V. Phone/Fax

Practice location:
  • Phone: 276-679-5390
  • Fax: 276-679-5395
Mailing address:
  • Phone: 423-408-7220
  • Fax: 423-408-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110004384
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: