Healthcare Provider Details

I. General information

NPI: 1760475891
Provider Name (Legal Business Name): VICTOR G BRIDGES PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 EMERALD AVE SUITE 905
KNOXVILLE TN
37917-4502
US

IV. Provider business mailing address

939 EMERALD AVE SUITE 905
KNOXVILLE TN
37917-4502
US

V. Phone/Fax

Practice location:
  • Phone: 865-647-3350
  • Fax: 865-647-3359
Mailing address:
  • Phone: 865-647-3350
  • Fax: 865-647-3359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number014
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: