=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689004046
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENDALL WASZ PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2013
-----------------------------------------------------
Last Update Date | 08/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4915 NORTON HEALTHCARE BLVD STE 301
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40241-2866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-635-7455
-----------------------------------------------------
Fax | 502-634-9296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1169 EASTERN PKWY STE 2265
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40217-1479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-635-7455
-----------------------------------------------------
Fax | 502-634-9296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA2365
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA2365
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------