Healthcare Provider Details

I. General information

NPI: 1245251404
Provider Name (Legal Business Name): WATAUGA ORTHOPAEDICS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 SUSANNAH ST
JOHNSON CITY TN
37601-1765
US

IV. Provider business mailing address

2410 SUSANNAH ST
JOHNSON CITY TN
37601-1765
US

V. Phone/Fax

Practice location:
  • Phone: 423-282-9011
  • Fax: 423-282-0035
Mailing address:
  • Phone: 423-282-9011
  • Fax: 423-282-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number18545
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberANP18364
License Number StateTN

VIII. Authorized Official

Name: KATHERINE ELIZABETH LYONS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 423-282-9011