=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669126926
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STANISLAVA GANTCHEVA PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2022
-----------------------------------------------------
Last Update Date | 09/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2195 HARRODSBURG RD FL 2
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40504-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-323-4263
-----------------------------------------------------
Fax | 859-323-2412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1221 S BROADWAY
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40504-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-258-6200
-----------------------------------------------------
Fax | 859-258-6203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA3148
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA3148
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA3148
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------