Individual
CHARLIE ETHERTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
1124 FOX MEADOWS BLVD, SUITE 2, SEVIERVILLE, TN 37862-6927
(865) 453-5530
(865) 453-2671
Mailing address
1275 DICK LONAS RD, KNOXVILLE, TN 37909-1382
(865) 584-4747
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA0842
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00339849
RR MEDICARE PIN
TN
Enumeration date
08/17/2006
Last updated
04/23/2020
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