Healthcare Provider Details

I. General information

NPI: 1265656136
Provider Name (Legal Business Name): PEDIATRIC & ADOLESCENT ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 N EAGLE CREEK DR
LEXINGTON KY
40509-1801
US

IV. Provider business mailing address

3050 HARRODSBURG RD
LEXINGTON KY
40503-2747
US

V. Phone/Fax

Practice location:
  • Phone: 859-977-3044
  • Fax: 859-977-0237
Mailing address:
  • Phone: 859-977-3044
  • Fax: 859-977-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTINA LANE PADILLA
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 859-977-3044