MEDICARE: ELKHORN PRIMARY CARE

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	363LF0000X	Family Nurse Practitioner	3007228	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780106591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELKHORN PRIMARY CARE

Provider Business Mailing Address
First Line	:	P.O. BOX 1432
Second Line	:
City	:	ELKHORN CITY
State	:	KY
Zip	:	41522-9043
Country	:	US
Telephone Number	:	606-754-5793
Fax Number	:	606-886-9908

Provider Business Practice Location Address
First Line	:	112 E MAIN ST
Second Line	:
City	:	ELKHORN CITY
State	:	KY
Zip	:	41522-9043
Country	:	US
Telephone Number	:	606-754-5793
Fax Number	:	606-886-9908

Authorized Official
Title or Position	:	OWNER
Name	:	CRYSTAL BRANHAM
Credential	:	NP
Telephone Number	:	606-754-5793

Provider Enumeration Date	:	07/13/2017
Last Update Date	:	07/13/2017

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Directions to “ELKHORN PRIMARY CARE ” Practice Location

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