Provider Demographics
NPI:1699103804
Name:FEDOR, NICHOLAS PETER (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PETER
Last Name:FEDOR
Suffix:
Gender:M
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:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37771-1008
Mailing Address - Country:US
Mailing Address - Phone:865-988-3666
Mailing Address - Fax:
Practice Address - Street 1:10820 PARKSIDE DR
Practice Address - Street 2:EMERGENCY DEPT.
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1956
Practice Address - Country:US
Practice Address - Phone:865-988-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2427363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant