Provider Demographics
NPI:1679283386
Name:MASHBURN, EMMA GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:GRACE
Last Name:MASHBURN
Suffix:
Gender:F
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 1:1809 CAMPFIRE DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37931-4346
Mailing Address - Country:US
Mailing Address - Phone:224-602-2252
Mailing Address - Fax:
Practice Address - Street 1:1809 CAMPFIRE DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37931-4346
Practice Address - Country:US
Practice Address - Phone:866-309-7449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2023-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1206649363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant