Healthcare Provider Details

I. General information

NPI: 1669157574
Provider Name (Legal Business Name): KARI BETH ROARK VERGNE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TRILLIUM WAY
CORBIN KY
40701-8426
US

IV. Provider business mailing address

292 VANOVER RD W
LONDON KY
40744-8978
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-1212
  • Fax:
Mailing address:
  • Phone: 606-359-4158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3205
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: