Basic Information
| Provider Information | |||||||||
| NPI: | 1124265871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCKHART | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70354 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402700354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024732132 | ||||||||
| FaxNumber: | 5024590923 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 KRESGE WAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024732132 | ||||||||
| FaxNumber: | 5024590923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2009 | ||||||||
| LastUpdateDate: | 12/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1103993 | KY | N | Nursing Service Providers | Registered Nurse | 367500000X | 3005916 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 7100080010 | 05 | KY | MEDICAID |