Healthcare Provider Details

I. General information

NPI: 1669686010
Provider Name (Legal Business Name): JAMES MICHAEL LAVELLE PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 BELLEFONTE PRINCESS RD
ASHLAND KY
41101-2272
US

IV. Provider business mailing address

810 BELLEFONTE PRINCESS RD
ASHLAND KY
41101-2272
US

V. Phone/Fax

Practice location:
  • Phone: 606-921-6805
  • Fax: 606-921-6332
Mailing address:
  • Phone: 606-921-6805
  • Fax: 606-921-6332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberKY 537
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: