Basic Information
| Provider Information | |||||||||
| NPI: | 1255752069 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORGAN | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | RANDOLPH | ||||||||
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| NameSuffix: | III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 VIRGINIA AVE NE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | NORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242731538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766795390 | ||||||||
| FaxNumber: | 2766795395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2013 | ||||||||
| LastUpdateDate: | 10/24/2014 | ||||||||
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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 | 363A00000X | 0110004384 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1255752069 | 05 | VA | MEDICAID | Q003803 | 05 | TN | MEDICAID |