MEDICARE: MR. BYRON D UNDERWOOD RNFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WR0006X	Registered Nurse First Assistant	1039549	KY

General Provider Information

NPI Number	:	1588803142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BYRON D UNDERWOOD RNFA

Provider Business Mailing Address
First Line	:	PO BOX 1033
Second Line	:
City	:	DANVILLE
State	:	KY
Zip	:	40423-1033
Country	:	US
Telephone Number	:	859-329-9105
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 BOONE TRAIL RD
Second Line	:
City	:	DANVILLE
State	:	KY
Zip	:	40422-1549
Country	:	US
Telephone Number	:	859-329-9105
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2009
Last Update Date	:	02/05/2009

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