Provider Demographics
NPI:1992736334
Name:TATUM, PHILLIP BRADLEY (FNP)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:BRADLEY
Last Name:TATUM
Suffix:
Gender:M
Credentials:FNP
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 916
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:TN
Mailing Address - Zip Code:37096-0916
Mailing Address - Country:US
Mailing Address - Phone:931-589-2104
Mailing Address - Fax:931-589-2513
Practice Address - Street 1:115 E BROOKLYN ST
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:TN
Practice Address - Zip Code:37096-3515
Practice Address - Country:US
Practice Address - Phone:931-589-2104
Practice Address - Fax:931-589-2513
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000012073363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner