Healthcare Provider Details

I. General information

NPI: 1740538966
Provider Name (Legal Business Name): JOSEPH TYE PREWITT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MOONBOW PLZ
CORBIN KY
40701-8949
US

IV. Provider business mailing address

3454 E LAUREL RD
LONDON KY
40741-6871
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-5331
  • Fax: 606-528-3223
Mailing address:
  • Phone: 606-231-8437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTC127
License Number StateKY

VIII. Authorized Official

Name: MRS. CHAWNTAY GILMORE
Title or Position: BILLING OFFICE MANAGER
Credential:
Phone: 606-526-8122