Healthcare Provider Details

I. General information

NPI: 1346225380
Provider Name (Legal Business Name): THOMAS WANNENBURG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9320 PARK WEST BLVD
KNOXVILLE TN
37923-4301
US

IV. Provider business mailing address

9320 PARK WEST BLVD
KNOXVILLE TN
37923-4301
US

V. Phone/Fax

Practice location:
  • Phone: 865-373-7100
  • Fax: 865-373-7101
Mailing address:
  • Phone: 865-373-7100
  • Fax: 865-373-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34761
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number34761
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number52414
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: