Provider Demographics
NPI:1366413874
Name:DEBORD, HAROLD LANCE (PA)
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:LANCE
Last Name:DEBORD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S MOHAWK DR STE E
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-2124
Mailing Address - Country:US
Mailing Address - Phone:423-330-6177
Mailing Address - Fax:423-330-6241
Practice Address - Street 1:800 S MOHAWK DR STE E
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-2124
Practice Address - Country:US
Practice Address - Phone:423-330-6177
Practice Address - Fax:423-330-6241
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002182363A00000X
TN1316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1503864Medicaid
TNQ27863Medicare UPIN