Basic Information
| Provider Information | |||||||||
| NPI: | 1952785081 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TENNESSEE STATE UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAMAR ELEMENTARY SCHOOL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 STOUT DRIVE BOX 70403 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394515 | ||||||||
| FaxNumber: | 4234395780 | ||||||||
| Practice Location | |||||||||
| Address1: | 3261 TN 81 | ||||||||
| Address2: | |||||||||
| City: | JONESBOROUGH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237531130 | ||||||||
| FaxNumber: | 4234394560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2015 | ||||||||
| LastUpdateDate: | 02/23/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | BETTY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ACTING CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4234394414 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.