Healthcare Provider Details

I. General information

NPI: 1962448860
Provider Name (Legal Business Name): TERRY L HALLWACHS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

988 OAK RIDGE TPKE SUITE 100
OAK RIDGE TN
37830-6930
US

IV. Provider business mailing address

308 N PETERS RD SUITE 225
KNOXVILLE TN
37922-2356
US

V. Phone/Fax

Practice location:
  • Phone: 865-483-8478
  • Fax: 865-483-4194
Mailing address:
  • Phone: 865-694-7725
  • Fax: 865-483-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3957
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1571
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1571
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: