Healthcare Provider Details

I. General information

NPI: 1902031602
Provider Name (Legal Business Name): SOMERSET PEDIATRIC SPECIALISTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 LANGDON ST
SOMERSET KY
42503-2786
US

IV. Provider business mailing address

350 LANGDON ST
SOMERSET KY
42503-2786
US

V. Phone/Fax

Practice location:
  • Phone: 606-678-8155
  • Fax:
Mailing address:
  • Phone: 606-678-8155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JANIE ISON
Title or Position: ASST. OFFICE MANAGER
Credential:
Phone: 606-678-8155