Healthcare Provider Details

I. General information

NPI: 1396536660
Provider Name (Legal Business Name): MR. JOHN TESTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3053 W STATE ST
BRISTOL TN
37620-1720
US

IV. Provider business mailing address

3053 W STATE ST
BRISTOL TN
37620-1720
US

V. Phone/Fax

Practice location:
  • Phone: 423-968-1144
  • Fax:
Mailing address:
  • Phone: 423-968-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: