Basic Information
| Provider Information | |||||||||
| NPI: | 1033105713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARCHER | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | ANP C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 S WILLOW AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385013138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315269518 | ||||||||
| FaxNumber: | 9313720087 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 S WILLOW AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385013138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315269518 | ||||||||
| FaxNumber: | 9313720087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 05/14/2012 | ||||||||
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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 | 363L00000X | RN0127285 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3909546 | 05 | TN | MEDICAID |