Healthcare Provider Details

I. General information

NPI: 1043546336
Provider Name (Legal Business Name): MARC EDWARD BLANKENSHIP RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 KINGSTON PIKE STE 540
KNOXVILLE TN
37919-5054
US

IV. Provider business mailing address

5401 KINGSTON PIKE STE 540
KNOXVILLE TN
37919-5054
US

V. Phone/Fax

Practice location:
  • Phone: 865-584-7376
  • Fax:
Mailing address:
  • Phone: 865-584-7376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License NumberRA 0000000010
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: