Healthcare Provider Details

I. General information

NPI: 1194471532
Provider Name (Legal Business Name): GARRETT AUSTIN FAULKNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 BRYAN BLVD
CORBIN KY
40701-2775
US

IV. Provider business mailing address

1615 MAIN ST
WILLIAMSBURG KY
40769-1842
US

V. Phone/Fax

Practice location:
  • Phone: 606-523-2005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3024
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: