Basic Information
| Provider Information | |||||||||
| NPI: | 1376965129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADAMS | ||||||||
| FirstName: | ELYSE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 N JAMES CAMPBELL BLVD | ||||||||
| Address2: | 200 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384012754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313812663 | ||||||||
| FaxNumber: | 9314901369 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 N JAMES CAMPBELL BLVD | ||||||||
| Address2: | 200 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384012754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313812663 | ||||||||
| FaxNumber: | 9314901369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2014 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3039 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 3039 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | Q006789 | 05 | TN | MEDICAID |