Provider Demographics
NPI:1538231949
Name:KINGMAN, WAYNETTE (PA-C)
Entity type:Individual
Prefix:MS
First Name:WAYNETTE
Middle Name:
Last Name:KINGMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4703
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:110 DEER XING
Practice Address - Street 2:
Practice Address - City:VONORE
Practice Address - State:TN
Practice Address - Zip Code:37885-2133
Practice Address - Country:US
Practice Address - Phone:423-884-1925
Practice Address - Fax:423-884-1926
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527899Medicaid
TN3664292Medicare ID - Type Unspecified