Basic Information
| Provider Information | |||||||||
| NPI: | 1043336373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HETMAN | ||||||||
| FirstName: | JOANNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950248 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022382801 | ||||||||
| FaxNumber: | 5022382835 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 EASTPOINT PKWY STE 450 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402234154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022446899 | ||||||||
| FaxNumber: | 5022446940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 42851 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3734342000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 000000629366 | 01 | KY | ANTHEM | OTHER | 50025480 | 01 | KY | PASSPORT | OTHER | 7100086660 | 05 | KY | MEDICAID |