Provider Demographics
NPI:1831117514
Name:HANEY, CHARLES L (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:HANEY
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 1:1932 ALCOA HWY
Mailing Address - Street 2:SUITE 255
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1527
Mailing Address - Country:US
Mailing Address - Phone:865-544-1869
Mailing Address - Fax:865-544-6533
Practice Address - Street 1:1932 ALCOA HWY
Practice Address - Street 2:SUITE 255
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1527
Practice Address - Country:US
Practice Address - Phone:865-544-1869
Practice Address - Fax:865-544-6533
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02309363A00000X
TN1522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3665105OtherMEDICARE
TN4164942OtherBCBS
TX87N249OtherBCBS
TN4164939OtherBCBS
TN3665105Medicaid
TN4164942OtherBCBS
TN3665105Medicaid