1508549296 NPI number — CAITLYN BLAIR HART PHYSICIAN ASSISTANT

Table of content: CAITLYN BLAIR HART PHYSICIAN ASSISTANT (NPI 1508549296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508549296 NPI number — CAITLYN BLAIR HART PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HART
Provider First Name:
CAITLYN
Provider Middle Name:
BLAIR
Provider Name Prefix Text:
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:
HARPER
Provider Other First Name:
CAITLYN
Provider Other Middle Name:
BLAIR
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508549296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 BRADDOCK DR APT C2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40207-4184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-854-6820
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
282 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06106-3322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-459-0008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2023

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:  6315 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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