Basic Information
| Provider Information | |||||||||
| NPI: | 1699230904 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WING | ||||||||
| FirstName: | DANIELLE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52948 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379502948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653065700 | ||||||||
| FaxNumber: | 8655847760 | ||||||||
| Practice Location | |||||||||
| Address1: | 6408 PAPERMILL DR | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379194858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655888229 | ||||||||
| FaxNumber: | 8652120163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2019 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 4591 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 4591 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | Q068951 | 05 | TN | MEDICAID |