Healthcare Provider Details

I. General information

NPI: 1083643274
Provider Name (Legal Business Name): JAMES E RAVENCRAFT II P.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 WINCHESTER AVE
ASHLAND KY
41101-7847
US

IV. Provider business mailing address

2222 WINCHESTER AVE
ASHLAND KY
41101-7847
US

V. Phone/Fax

Practice location:
  • Phone: 606-325-9644
  • Fax:
Mailing address:
  • Phone: 606-325-9644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA336
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: