Basic Information
| Provider Information | |||||||||
| NPI: | 1992240808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOCKEY | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | DWAYNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 828 WINCHESTER DR | ||||||||
| Address2: | |||||||||
| City: | GREENEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377436050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236204558 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 N STATE OF FRANKLIN RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234316111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/01/2017 | ||||||||
| LastUpdateDate: | 01/01/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN0000022052 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.