Provider Demographics
NPI:1265996672
Name:VON FANGE, JESSE E (PA-C)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:E
Last Name:VON FANGE
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 1:1275 DICK LONAS RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1383
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:280 FORT SANDERS WEST BLVD STE 101
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3352
Practice Address - Country:US
Practice Address - Phone:865-539-0270
Practice Address - Fax:865-539-6998
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3804363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical