Provider Demographics
NPI:1164813606
Name:RUNYAN, KATHERINE CLARK (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:CLARK
Last Name:RUNYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:HARGRAVE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1275 DICK LONAS RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1383
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:8975 EXECUTIVE PARK DR.
Practice Address - Street 2:SUITE 200
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-3624
Practice Address - Country:US
Practice Address - Phone:865-691-4100
Practice Address - Fax:865-691-6178
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ013463Medicaid
TN103I971896Medicare PIN