Basic Information
| Provider Information | |||||||||
| NPI: | 1003849803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STALEY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32569 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379302569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656940062 | ||||||||
| FaxNumber: | 8656947907 | ||||||||
| Practice Location | |||||||||
| Address1: | 9430 PARK WEST BLVD STE 230 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655608550 | ||||||||
| FaxNumber: | 8655608551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT0000003108 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 004814 | KY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 36590211 | 05 | TN | MEDICAID |