Healthcare Provider Details

I. General information

NPI: 1659929859
Provider Name (Legal Business Name): CODY WELCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST # MS 477
LEXINGTON KY
40536-7001
US

IV. Provider business mailing address

437 ARLINGTON MEADOWS DR
FISHERVILLE KY
40023-7749
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-1850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC865
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPENDING
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2592
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: