Provider Demographics
NPI:1679265490
Name:FUSSELL, JOHN THOMAS (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:FUSSELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 HUNTER LN
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061-4169
Mailing Address - Country:US
Mailing Address - Phone:931-289-9189
Mailing Address - Fax:
Practice Address - Street 1:9785 HIGHWAY 79 S
Practice Address - Street 2:
Practice Address - City:HENRY
Practice Address - State:TN
Practice Address - Zip Code:38231-3613
Practice Address - Country:US
Practice Address - Phone:731-243-1450
Practice Address - Fax:731-243-1000
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
TN5567363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical