Healthcare Provider Details

I. General information

NPI: 1013954510
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321C E COLLEGE AVE
STANTON KY
40380-2325
US

IV. Provider business mailing address

PO BOX 2748
PIKEVILLE KY
41502-2748
US

V. Phone/Fax

Practice location:
  • Phone: 606-663-9797
  • Fax: 606-663-9470
Mailing address:
  • Phone: 606-432-3221
  • Fax: 606-437-0438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number900183
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3006123
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1161
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number900183
License Number StateKY

VIII. Authorized Official

Name: DJIEN HWAT SO
Title or Position: OPERATING MANAGER
Credential:
Phone: 606-432-0174