1508257783 NPI number — MALLORY L BARTRAM PA-C

Table of content: MALLORY L BARTRAM PA-C (NPI 1508257783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508257783 NPI number — MALLORY L BARTRAM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARTRAM
Provider First Name:
MALLORY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUCKOSH
Provider Other First Name:
MALLORY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508257783
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 ROSE ST
Provider Second Line Business Mailing Address:
MS-463
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40536-0202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-323-0100
Provider Business Mailing Address Fax Number:
859-257-6066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 ROSE ST
Provider Second Line Business Practice Location Address:
MS-463
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40536-0202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-323-0100
Provider Business Practice Location Address Fax Number:
859-257-6066
Provider Enumeration Date:
02/10/2015

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 , with the licence number:  PA1985 , 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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