Healthcare Provider Details

I. General information

NPI: 1841350162
Provider Name (Legal Business Name): MARK DYER FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 SHELBYVILLE RD
LOUISVILLE KY
40243-1419
US

IV. Provider business mailing address

506 EDGEFOREST PLACE
LOUISVILLE KY
40245
US

V. Phone/Fax

Practice location:
  • Phone: 502-883-2218
  • Fax:
Mailing address:
  • Phone: 502-845-6288
  • Fax: 502-845-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3535P
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: