Basic Information
| Provider Information | |||||||||
| NPI: | 1043283393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POCZATEK | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | VANCEBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411790550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067963029 | ||||||||
| FaxNumber: | 6067966221 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 ELIZAVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | FLEMINGSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410411141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068450028 | ||||||||
| FaxNumber: | 6068450263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 02/21/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3923P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 3003923 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 78008778 | 05 | KY | MEDICAID |