Provider Demographics
NPI:1063767473
Name:NETHERLAND, ROBERT J (NP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:NETHERLAND
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2000 BROOKSIDE DR
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4627
Mailing Address - Country:US
Mailing Address - Phone:423-857-5905
Mailing Address - Fax:423-857-5904
Practice Address - Street 1:2000 BROOKSIDE DR
Practice Address - Street 2:3RD FLOOR
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4627
Practice Address - Country:US
Practice Address - Phone:423-857-5905
Practice Address - Fax:423-857-5904
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN16816363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01312579OtherRAILROAD MEDICARE
KY7100220310Medicaid
VA1063767473Medicaid
TN1530134Medicaid
NC1063767473Medicaid
TN103I507723Medicare PIN