Healthcare Provider Details

I. General information

NPI: 1790940146
Provider Name (Legal Business Name): MELISSA BLAIR WHITAKER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BLAIR WHITAKER PA-C

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 LEGENDS WAY
CRESTVIEW HILLS KY
41017
US

IV. Provider business mailing address

2616 LEGENDS WAY
CRESTVIEW HILLS KY
41017-2418
US

V. Phone/Fax

Practice location:
  • Phone: 859-331-3100
  • Fax:
Mailing address:
  • Phone: 859-331-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001781A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008619
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1130
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: