Healthcare Provider Details

I. General information

NPI: 1164813606
Provider Name (Legal Business Name): KATHERINE CLARK RUNYAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE HARGRAVE CLARK PA

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8975 EXECUTIVE PARK DR. SUITE 200
KNOXVILLE TN
37923-3624
US

IV. Provider business mailing address

1275 DICK LONAS RD UNIT 101
KNOXVILLE TN
37909-1383
US

V. Phone/Fax

Practice location:
  • Phone: 865-691-4100
  • Fax: 865-691-6178
Mailing address:
  • Phone: 865-584-4747
  • Fax: 865-584-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2711
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: