Healthcare Provider Details

I. General information

NPI: 1134140494
Provider Name (Legal Business Name): JENNIFER A. RAISLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE K401
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

740 S LIMESTONE K401
LEXINGTON KY
40536-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5533
  • Fax: 859-323-2412
Mailing address:
  • Phone: 859-323-5533
  • Fax: 859-323-2412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA993
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA993
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA993
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: