Healthcare Provider Details

I. General information

NPI: 1639160815
Provider Name (Legal Business Name): JAMES RICHARD RISNEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W OAKLAND AVE SUITE 102
JOHNSON CITY TN
37604-2191
US

IV. Provider business mailing address

1021 W OAKLAND AVE SUITE 102
JOHNSON CITY TN
37604-2191
US

V. Phone/Fax

Practice location:
  • Phone: 423-928-9014
  • Fax: 423-928-3559
Mailing address:
  • Phone: 423-928-9014
  • Fax: 423-928-3559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA0000000411
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: