Basic Information
| Provider Information | |||||||||
| NPI: | 1255371134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANCE | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11201 WEST POINT DR | ||||||||
| Address2: | SUITE 102 FARRAGUT FAMILY PRACTICE | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379342834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656751953 | ||||||||
| FaxNumber: | 8656750877 | ||||||||
| Practice Location | |||||||||
| Address1: | 11201 WEST POINT DR | ||||||||
| Address2: | SUITE 102 FARRAGUT FAMILY PRACTICE | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379342834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656751953 | ||||||||
| FaxNumber: | 8656750877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 12/18/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PA0000000311 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | TN0106 | 01 | JDH | OTHER |