MEDICARE: KARLI QUALLS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2443	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6093446	OTHER	TN	BCBS

General Provider Information

NPI Number	:	1679904494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARLI QUALLS PA-C

Provider Business Mailing Address
First Line	:	228 W 4TH ST
Second Line	:	SUITE 200
City	:	COOKEVILLE
State	:	TN
Zip	:	38501-2488
Country	:	US
Telephone Number	:	931-372-0405
Fax Number	:	931-372-0463

Provider Business Practice Location Address
First Line	:	228 W 4TH ST
Second Line	:	SUITE 200
City	:	COOKEVILLE
State	:	TN
Zip	:	38501-2488
Country	:	US
Telephone Number	:	931-372-0405
Fax Number	:	931-372-0463

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2013
Last Update Date	:	06/17/2022

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