Provider Demographics
NPI:1356334973
Name:MCCRARY, THEODORE W (PAC)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:W
Last Name:MCCRARY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S GALLAHER VIEW RD STE 224
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-5361
Mailing Address - Country:US
Mailing Address - Phone:865-951-2012
Mailing Address - Fax:865-951-2575
Practice Address - Street 1:301 S GALLAHER VIEW RD STE 224
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5361
Practice Address - Country:US
Practice Address - Phone:865-951-2012
Practice Address - Fax:865-951-2575
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3666869Medicaid
TN0677340001Medicare NSC
3666869Medicare ID - Type Unspecified
S34097Medicare UPIN