Provider Demographics
NPI:1871528976
Name:BOONES CREEK MEDICAL PLLC
Entity type:Organization
Organization Name:BOONES CREEK MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:423-282-0636
Mailing Address - Street 1:1000 W JACKSON BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-5397
Mailing Address - Country:US
Mailing Address - Phone:423-282-1990
Mailing Address - Fax:423-282-1990
Practice Address - Street 1:2685 BOONES CREEK ROAD
Practice Address - Street 2:SUITE 104
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615
Practice Address - Country:US
Practice Address - Phone:423-282-0636
Practice Address - Fax:423-282-1990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3735590Medicaid
TN3735590Medicaid