MEDICARE: SARAH E GRISSOM 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	363AM0700X	Medical Physician Assistant	016538	NY
2	363AM0700X	Medical Physician Assistant	0010-01972	NC
3	363A00000X	Physician Assistant	3294	TN

General Provider Information

NPI Number	:	1932432416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH E GRISSOM PA-C

Provider Business Mailing Address
First Line	:	4101 DAYTON BLVD
Second Line	:
City	:	RED BANK
State	:	TN
Zip	:	37415-7156
Country	:	US
Telephone Number	:	423-499-7710
Fax Number	:	423-499-7711

Provider Business Practice Location Address
First Line	:	4101 DAYTON BLVD
Second Line	:
City	:	RED BANK
State	:	TN
Zip	:	37415-7156
Country	:	US
Telephone Number	:	423-499-7710
Fax Number	:	423-499-7711

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

Provider Enumeration Date	:	09/15/2009
Last Update Date	:	05/08/2023

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Directions to “ SARAH E GRISSOM PA-C” Practice Location

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