Provider Demographics
NPI:1104059765
Name:EMBREY, PRESTON PARKER (PA)
Entity type:Individual
Prefix:MR
First Name:PRESTON
Middle Name:PARKER
Last Name:EMBREY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 PARR AVE STE C
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2071
Mailing Address - Country:US
Mailing Address - Phone:731-286-4445
Mailing Address - Fax:731-286-4452
Practice Address - Street 1:1718 PARR AVE STE C
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2071
Practice Address - Country:US
Practice Address - Phone:731-286-4445
Practice Address - Fax:731-286-4452
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1768363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4245228OtherBCBS PA
TN1516451Medicaid
TN4245266OtherBCBS PA SURGERY
TN4245228OtherBCBS PA