Basic Information
| Provider Information | |||||||||
| NPI: | 1104125210 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WATAUGA ORTHOPAEDICS, PLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WATAUGA ORTHOPAEDICS OF KINGSPORT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2410 SUSANNAH STREET | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232829011 | ||||||||
| FaxNumber: | 4232820035 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 LARRY NEIL WAY | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232829011 | ||||||||
| FaxNumber: | 4232820035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4232829582 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363A00000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 332B00000X | TN | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 3706248 | 05 | TN | MEDICAID |