Basic Information
| Provider Information | |||||||||
| NPI: | 1013179860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YAWN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 NEW SHACKLE ISLAND RD STE 300C | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370752384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158240043 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 353 NEW SHACKLE ISLAND RD STE 300C | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370752384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158240043 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2008 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 73889 | GA | N | Other Service Providers | Specialist | 207RI0011X | 55661 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 003163121A | 05 | GA | MEDICAID | 13587267 | 01 | GA | CAQH | OTHER |