Provider Demographics
NPI:1164441598
Name:HOSTLER, WAYNE MATTHEW (PA)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:MATTHEW
Last Name:HOSTLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:WAYNE
Other - Middle Name:LAMONT
Other - Last Name:HOSTLER
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2050 MEADOWVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-7332
Mailing Address - Country:US
Mailing Address - Phone:423-230-5000
Mailing Address - Fax:423-230-5010
Practice Address - Street 1:2050 MEADOWVIEW PKWY
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7332
Practice Address - Country:US
Practice Address - Phone:423-230-5000
Practice Address - Fax:423-230-5010
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1268363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN010236193Medicaid
IL0182OtherJOHN DEERE
TN4108134OtherBLUE CRSS BLUE SHIELD
TNP32259Medicare UPIN
TN010236193Medicaid