Healthcare Provider Details

I. General information

NPI: 1205189404
Provider Name (Legal Business Name): JEREMY DAVID CAUDILL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S 3RD ST STE B
DANVILLE KY
40422-2016
US

IV. Provider business mailing address

333 S 3RD ST STE B
DANVILLE KY
40422-2016
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-8730
  • Fax: 859-236-4468
Mailing address:
  • Phone: 859-236-8730
  • Fax: 859-236-4468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1779
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: