Healthcare Provider Details

I. General information

NPI: 1629752514
Provider Name (Legal Business Name): TAVIS D. CLONCH P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 MED TECH PKWY STE 300
JOHNSON CITY TN
37604-2365
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 423-232-8301
  • Fax: 423-232-8304
Mailing address:
  • Phone: 423-952-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5560
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009515
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: