Healthcare Provider Details

I. General information

NPI: 1346661865
Provider Name (Legal Business Name): PIONEER FOOT AND ANKLE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2013
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 MIDWAY ST
BRISTOL TN
37620-1706
US

IV. Provider business mailing address

926 WEST OAKLAND AVE STE 206
JOHNSON CITY TN
37604-4100
US

V. Phone/Fax

Practice location:
  • Phone: 423-854-0001
  • Fax: 423-854-0002
Mailing address:
  • Phone: 423-854-0001
  • Fax: 423-854-0002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDPM732
License Number StateTN

VIII. Authorized Official

Name: DR. PAUL KENT WILSON
Title or Position: OWNER
Credential: MD
Phone: 423-854-0001