Provider Demographics
NPI:1124725692
Name:PENDERGRASS, JOE TAYLOR (RN)
Entity type:Individual
Prefix:MR
First Name:JOE
Middle Name:TAYLOR
Last Name:PENDERGRASS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 BRISTOL CAVERNS HWY
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-9456
Mailing Address - Country:US
Mailing Address - Phone:423-534-6322
Mailing Address - Fax:
Practice Address - Street 1:804 BRISTOL CAVERNS HWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-9456
Practice Address - Country:US
Practice Address - Phone:423-534-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN222207163WC0200X
TN36044367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine