Healthcare Provider Details

I. General information

NPI: 1699410548
Provider Name (Legal Business Name): PATRIOT ONE PRIMARY CARE PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 08/02/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

989 GOVERNORS LN STE 220
LEXINGTON KY
40513-1175
US

IV. Provider business mailing address

989 GOVERNORS LN STE 220
LEXINGTON KY
40513-1175
US

V. Phone/Fax

Practice location:
  • Phone: 859-447-8014
  • Fax: 859-447-8013
Mailing address:
  • Phone: 859-447-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH MENTZER
Title or Position: OWNER
Credential: PA-C
Phone: 859-447-8014