Basic Information
| Provider Information | |||||||||
| NPI: | 1568642692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAMBLIN | ||||||||
| FirstName: | ALLISON | ||||||||
| MiddleName: | LAYNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOGUE | ||||||||
| OtherFirstName: | ALLISON | ||||||||
| OtherMiddleName: | LAYNE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15 STONEBRIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383052042 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15 STONEBRIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383052042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316602056 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2007 | ||||||||
| LastUpdateDate: | 03/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1939 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA05500 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 192433402 | 05 | TX | MEDICAID | 8Y8266 | 01 | TX | BCBSTX | OTHER | 8Y3249 | 01 | TX | BCBS | OTHER |