Basic Information
| Provider Information | |||||||||
| NPI: | 1003231432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATTENBERGER | ||||||||
| FirstName: | DUSTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636493 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815130 | ||||||||
| FaxNumber: | 5139815015 | ||||||||
| Practice Location | |||||||||
| Address1: | 9390 BUNSEN PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402203789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8333582278 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2014 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3008537 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100291580 | 05 | KY | MEDICAID |