Healthcare Provider Details

I. General information

NPI: 1336101179
Provider Name (Legal Business Name): PURCHASE DERM-ENT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 KENTUCKY AVENUE DOB 3, SUITE 601
PADUCAH KY
42003-3800
US

IV. Provider business mailing address

2605 KENTUCKY AVENUE DOB 3, SUITE 601
PADUCAH KY
42003-3800
US

V. Phone/Fax

Practice location:
  • Phone: 270-408-4368
  • Fax: 570-408-3272
Mailing address:
  • Phone: 270-408-4368
  • Fax: 570-408-3272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHAWN C JONES
Title or Position: PARTNER
Credential: M.D.
Phone: 570-408-4368