Provider Demographics
NPI:1417331059
Name:SMIDDY, JOHN WESLEY (NP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
Last Name:SMIDDY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 JACKSBORO PIKE
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-4850
Mailing Address - Country:US
Mailing Address - Phone:423-201-9937
Mailing Address - Fax:423-567-4722
Practice Address - Street 1:2702 JACKSBORO PIKE
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-4850
Practice Address - Country:US
Practice Address - Phone:423-201-9937
Practice Address - Fax:423-567-4722
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20145363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner