Provider Demographics
NPI:1447301932
Name:DOUGLAS, DONALD R (PA)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:R
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10321 KINGSTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3224
Mailing Address - Country:US
Mailing Address - Phone:865-584-3565
Mailing Address - Fax:865-584-2956
Practice Address - Street 1:10321 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3224
Practice Address - Country:US
Practice Address - Phone:865-584-3565
Practice Address - Fax:865-584-2956
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000000766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP15267Medicare UPIN