Healthcare Provider Details

I. General information

NPI: 1225390891
Provider Name (Legal Business Name): KAITLYN DIANE TUCKER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 11/14/2020
Certification Date: 11/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 DUTCHMANS PKWY STE 345
LOUISVILLE KY
40205-3370
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-587-6010
  • Fax: 502-587-1314
Mailing address:
  • Phone: 502-587-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number006465
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: