Provider Demographics
NPI:1831130731
Name:THORNTON, NICHOLAS P IV (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:P
Last Name:THORNTON
Suffix:IV
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 1:1275 DICK LONAS RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1383
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:201 E EMORY RD
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4016
Practice Address - Country:US
Practice Address - Phone:865-938-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP0155783OtherRR MEDICARE PIN
TN3889692Medicaid
TNP0155783OtherRR MEDICARE PIN
TN3706636Medicare ID - Type UnspecifiedLEGACY GROUP
TN3889692Medicaid