Basic Information
Provider Information | |||||||||
NPI: | 1164813606 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUNYAN | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | CLARK | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CLARK | ||||||||
OtherFirstName: | KATHERINE | ||||||||
OtherMiddleName: | HARGRAVE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1275 DICK LONAS RD UNIT 101 | ||||||||
Address2: |   | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379091383 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8655844747 | ||||||||
FaxNumber: | 8655841363 | ||||||||
Practice Location | |||||||||
Address1: | 8975 EXECUTIVE PARK DR. | ||||||||
Address2: | SUITE 200 | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379233624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8656914100 | ||||||||
FaxNumber: | 8656916178 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2015 | ||||||||
LastUpdateDate: | 02/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2711 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | Q013463 | 05 | TN |   | MEDICAID |