Provider Demographics
NPI:1720092307
Name:BLACK, TIMOTHY R (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:R
Last Name:BLACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10800 PARKSIDE DR STE 330
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-1926
Mailing Address - Country:US
Mailing Address - Phone:865-218-7480
Mailing Address - Fax:865-218-7488
Practice Address - Street 1:10800 PARKSIDE DR STE 330
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1926
Practice Address - Country:US
Practice Address - Phone:865-218-7480
Practice Address - Fax:865-218-7488
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4012578Medicaid
TN3669361Medicare PIN