Healthcare Provider Details

I. General information

NPI: 1659027043
Provider Name (Legal Business Name): PADUCAH VASCULAR INSTITUTE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2419 NEW HOLT RD
PADUCAH KY
42001-7455
US

IV. Provider business mailing address

2419 NEW HOLT RD
PADUCAH KY
42001-7455
US

V. Phone/Fax

Practice location:
  • Phone: 270-845-4300
  • Fax: 270-845-4301
Mailing address:
  • Phone: 270-845-4300
  • Fax: 270-845-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: SCOTT SANDERS
Title or Position: OWNER
Credential: MD
Phone: 270-845-4300