Provider Demographics
NPI:1669478525
Name:SKINNER, WENDELL LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:LAWRENCE
Last Name:SKINNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-4000
Practice Address - Fax:423-224-3258
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4120208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6404261700Medicaid
TN31818611Medicaid
KY6404261700Medicaid
TN103I022875Medicare PIN
TN31818611Medicare PIN
TN31818611Medicaid