Healthcare Provider Details

I. General information

NPI: 1740084862
Provider Name (Legal Business Name): PEYTON GRACE MORRIS RISTAU DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 LANGDON ST
SOMERSET KY
42503-2750
US

IV. Provider business mailing address

287 LONE OAK DR
SOMERSET KY
42503-3720
US

V. Phone/Fax

Practice location:
  • Phone: 606-451-5093
  • Fax:
Mailing address:
  • Phone: 606-594-3788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: