Healthcare Provider Details

I. General information

NPI: 1841722980
Provider Name (Legal Business Name): ELKHORN DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 BOSTON SQ
GEORGETOWN KY
40324-9786
US

IV. Provider business mailing address

304 BOSTON SQ
GEORGETOWN KY
40324-9786
US

V. Phone/Fax

Practice location:
  • Phone: 502-316-9425
  • Fax: 502-316-9451
Mailing address:
  • Phone: 502-316-9425
  • Fax: 502-316-9451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number49577
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHASE WILSON
Title or Position: OWNER
Credential: MD
Phone: 502-316-9425