Provider Demographics
NPI:1508869348
Name:BACKUS, KATHRYN (NP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:
Last Name:BACKUS
Suffix:
Gender:F
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:2033 MEADOWVIEW LN
Practice Address - Street 2:STE 200
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7569
Practice Address - Country:US
Practice Address - Phone:423-857-2260
Practice Address - Fax:423-857-2261
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN 6139363LP0200X
VA0024070828363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007787031Medicaid
TN3348978Medicaid
TNPENDINGMedicaid
VA007787031Medicaid
R83345Medicare UPIN
0281780003Medicare PIN
TNPENDINGMedicaid