Healthcare Provider Details

I. General information

NPI: 1497892103
Provider Name (Legal Business Name): PADUCAH PRIMARY CARE, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 VILLAGE SQUARE DR
PADUCAH KY
42001-7501
US

IV. Provider business mailing address

2601 KENTUCKY AVE SUITE 101
PADUCAH KY
42003-3817
US

V. Phone/Fax

Practice location:
  • Phone: 270-442-8575
  • Fax: 270-442-8783
Mailing address:
  • Phone: 270-442-8575
  • Fax: 270-442-8783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD L WILSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 270-442-8575