Healthcare Provider Details

I. General information

NPI: 1548262090
Provider Name (Legal Business Name): KRISTA J TREVATHAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3310 RUCKRIEGEL PKWY
JEFFERSONTOWN KY
40299-3764
US

IV. Provider business mailing address

110 CHASE WAY STE 2
ELIZABETHTOWN KY
42701-7827
US

V. Phone/Fax

Practice location:
  • Phone: 502-212-0071
  • Fax: 502-996-8359
Mailing address:
  • Phone: 502-212-0071
  • Fax: 502-996-8359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA238
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA238
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA238
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: