Healthcare Provider Details

I. General information

NPI: 1578242897
Provider Name (Legal Business Name): PENGXIAO CAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 BROWNSBORO RD
LOUISVILLE KY
40241-1200
US

IV. Provider business mailing address

2620 ELM HILL PIKE
NASHVILLE TN
37214-3108
US

V. Phone/Fax

Practice location:
  • Phone: 502-618-8317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3018907
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: