Healthcare Provider Details

I. General information

NPI: 1275902744
Provider Name (Legal Business Name): NATASHA UNDERWOOD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TRILLIUM WAY
CORBIN KY
40701-8727
US

IV. Provider business mailing address

PO BOX 2828
LONDON KY
40743-2828
US

V. Phone/Fax

Practice location:
  • Phone: 606-526-4449
  • Fax:
Mailing address:
  • Phone: 606-309-1806
  • Fax: 606-657-5734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2059
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: