MEDICARE: AVA CARLISLE FUGATE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	TC14	KY

General Provider Information

NPI Number	:	1326877077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AVA CARLISLE FUGATE PA-C

Provider Business Mailing Address
First Line	:	2296 VALENCIA DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40513-0907
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1780 NICHOLASVILLE RD STE 403
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1413
Country	:	US
Telephone Number	:	859-260-6348
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2024
Last Update Date	:	07/31/2024

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