Healthcare Provider Details

I. General information

NPI: 1487633426
Provider Name (Legal Business Name): DAMON NEWSOME JR. P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 09/18/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 PARKWAY DR
SALYERSVILLE KY
41465-9251
US

IV. Provider business mailing address

1709 KY ROUTE 321
PRESTONSBURG KY
41653-9097
US

V. Phone/Fax

Practice location:
  • Phone: 606-298-3412
  • Fax: 606-298-5123
Mailing address:
  • Phone: 606-886-8546
  • Fax: 606-886-8548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024870
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number24870
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: