Basic Information
| Provider Information | |||||||||
| NPI: | 1205162252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | LUCAS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | UK DIVISION OF DIGESTIVE DISEASES | ||||||||
| Address2: | 800 ROSE STREET, MN649 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593234887 | ||||||||
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| Practice Location | |||||||||
| Address1: | UK DIVISION OF DIGESTIVE DISEASES | ||||||||
| Address2: | 740 S. LIMESTONE, 2ND FLOOR | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593230079 | ||||||||
| FaxNumber: | 8592579287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2009 | ||||||||
| LastUpdateDate: | 05/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA1219 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA1219 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA1219 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100104090 | 05 | KY | MEDICAID |