Basic Information
| Provider Information | |||||||||
| NPI: | 1861900870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MABRY | ||||||||
| FirstName: | HANNAH | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9129 CROSS PARK DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656947725 | ||||||||
| FaxNumber: | 8656738007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1819 W CLINCH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379162435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655245365 | ||||||||
| FaxNumber: | 8656738007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2018 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3376145 | 05 | TN | MEDICAID |