Provider Demographics
NPI:1427069749
Name:PRESLEY, JOHNNY WAYNE (PAC)
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:WAYNE
Last Name:PRESLEY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2861
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38557-2861
Mailing Address - Country:US
Mailing Address - Phone:931-879-5864
Mailing Address - Fax:
Practice Address - Street 1:100 S DUNCAN ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:TN
Practice Address - Zip Code:38556-3009
Practice Address - Country:US
Practice Address - Phone:931-879-5864
Practice Address - Fax:931-879-3903
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA130363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970004425OtherRAIL ROAD MEDICARE
R95976Medicare UPIN
TN3665953Medicare ID - Type Unspecified