Provider Demographics
NPI:1255371134
Name:VANCE, JERRY (PAC)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:VANCE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11201 WEST POINT DR
Mailing Address - Street 2:SUITE 102 FARRAGUT FAMILY PRACTICE
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2834
Mailing Address - Country:US
Mailing Address - Phone:865-675-1953
Mailing Address - Fax:865-675-0877
Practice Address - Street 1:11201 WEST POINT DR
Practice Address - Street 2:SUITE 102 FARRAGUT FAMILY PRACTICE
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2834
Practice Address - Country:US
Practice Address - Phone:865-675-1953
Practice Address - Fax:865-675-0877
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNPA0000000311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0106OtherJDH
R08839Medicare UPIN
TN0106OtherJDH