1619143146 NPI number — MISS JILL DELANA SHORT PHYSICIAN ASSISTANT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619143146 NPI number — MISS JILL DELANA SHORT PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHORT
Provider First Name:
JILL
Provider Middle Name:
DELANA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619143146
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
606 LINCOLN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAINTSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41240-1470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-638-4595
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
412 N LOCK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41230-1115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-638-4595
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA442 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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