Provider Demographics
NPI:1427461755
Name:RUTHERFORD, ROBERT (NP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:RUTHERFORD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2093
Mailing Address - Fax:
Practice Address - Street 1:105 W STONE DR STE 1F
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-230-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171932363LF0000X
TN18817363LF0000X
TN162686163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVE529BMedicare PIN
TN103I500828Medicare PIN