Provider Demographics
NPI:1891055950
Name:STILTNER, VICKI (PA)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:STILTNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 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 1:280 FORT SANDERS WEST BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3351
Practice Address - Country:US
Practice Address - Phone:865-539-2579
Practice Address - Fax:865-539-1502
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528694Medicaid