1619647468 NPI number — KURT EDWARD WILHELMUS PA-C

Table of content: KURT EDWARD WILHELMUS PA-C (NPI 1619647468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619647468 NPI number — KURT EDWARD WILHELMUS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILHELMUS
Provider First Name:
KURT
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1619647468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
87 LANTERN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NICHOLASVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40356-9009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-576-8037
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 WELLINGTON WAY STE 140
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40503-1387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-636-1394
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2021

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA2918 . This is a "STATE PHYSICIAN ASSISTANT LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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