Healthcare Provider Details

I. General information

NPI: 1205399508
Provider Name (Legal Business Name): MICHAEL DAVID THACKER FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 PRINCETON RD STE 3
JOHNSON CITY TN
37601-2040
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 423-302-3681
  • Fax: 423-302-3689
Mailing address:
  • Phone: 423-952-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25386
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number00241777354
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: