Provider Demographics
NPI:1104900547
Name:GERDOM, LARRY ERNEST (PA-C)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ERNEST
Last Name:GERDOM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:4010 WELLINGTON CT
Mailing Address - Street 2:
Mailing Address - City:OLD HICKORY
Mailing Address - State:TN
Mailing Address - Zip Code:37138-4657
Mailing Address - Country:US
Mailing Address - Phone:615-758-0476
Mailing Address - Fax:615-248-1622
Practice Address - Street 1:333 MURFREESBORO RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37210-2834
Practice Address - Country:US
Practice Address - Phone:615-248-1261
Practice Address - Fax:615-248-1622
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNPA0000001329363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant