Basic Information
| Provider Information | |||||||||
| NPI: | 1407143480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKINNER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 W BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378014703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731752 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 ASSOCIATES BLVD | ||||||||
| Address2: | |||||||||
| City: | ALCOA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377011943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652386400 | ||||||||
| FaxNumber: | 8652386404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2011 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | DO0000002977 | TN | Y | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | DO0000002977 | TN | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | Q022112 | 05 | TN | MEDICAID |