1730374794 NPI number — KARA TRAVIS MUDD PA-C

Table of content: KARA TRAVIS MUDD PA-C (NPI 1730374794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730374794 NPI number — KARA TRAVIS MUDD PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUDD
Provider First Name:
KARA
Provider Middle Name:
TRAVIS
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:
TRAVIS
Provider Other First Name:
KARA
Provider Other Middle Name:
RENEE
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:
1730374794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 950132
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:
40295-0132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-980-8992
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3810 SPRINGHURST BLVD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-583-1749
Provider Business Practice Location Address Fax Number:
502-329-8184
Provider Enumeration Date:
09/12/2007

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:  PA1064 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA1064 , 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)

  • Identifier: 3704756000 . This is a "PASSPORT ADVANTAGE- NORTON ORTHO TRAUMA CARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 611276316-106 . This is a "TRICARE- NORTON ORTHO TRAUMA CARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100040740 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00764030 . This is a "RAILROAD MEDICARE- NORTON ORTHO TRAUMA CARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000608608 . This is a "ANTHEM- NORTON ORTHO TRAUMA CARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000023035V . This is a "HUMANA- NORTON ORTHO TRAUMA CARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 00533117 . This is a "MEDICARE- NORTON ORTHO TRAUMA CARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50023180 . This is a "PASSPORT- NORTON ORTHO TRAUMA CARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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