Provider Demographics
NPI:1780846428
Name:BARTLEY, DAMON TROY (PA)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:TROY
Last Name:BARTLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 MEADOWVIEW PARKWAY
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-230-5000
Mailing Address - Fax:423-230-5097
Practice Address - Street 1:ONE MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 458W
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-844-4975
Practice Address - Fax:423-844-4987
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001498A363A00000X, 363AS0400X
363AS0400X
OH50-003027363AS0400X
TN1601363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508056Medicaid