Provider Demographics
NPI:1700990025
Name:ETHERTON, CHARLIE (PAC)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:ETHERTON
Suffix:
Gender:M
Credentials:PAC
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
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1382
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:
Practice Address - Street 1:1124 FOX MEADOWS BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-6927
Practice Address - Country:US
Practice Address - Phone:865-453-5530
Practice Address - Fax:865-453-2671
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00339849OtherRR MEDICARE PIN
P39951Medicare UPIN
TNP00339849OtherRR MEDICARE PIN
TN3669896Medicare ID - Type UnspecifiedLEGACY PIN