Provider Demographics
NPI:1306882345
Name:LAVELLE, MATTHEW T (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:T
Last Name:LAVELLE
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 1:423 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-5640
Mailing Address - Country:US
Mailing Address - Phone:865-271-6600
Mailing Address - Fax:
Practice Address - Street 1:423 MEDICAL PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5640
Practice Address - Country:US
Practice Address - Phone:865-271-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510649Medicaid
TNP00178344OtherRR MEDICARE PIN
Q27380Medicare UPIN
TN3717544Medicare ID - Type UnspecifiedLEGACY GROUP