Basic Information
Provider Information | |||||||||
NPI: | 1245616291 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SILLS | ||||||||
FirstName: | RUTH | ||||||||
MiddleName: | MARIA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LOGAN | ||||||||
OtherFirstName: | RUTH | ||||||||
OtherMiddleName: | SILLS | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PAC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1515 FONTAINE RD | ||||||||
Address2: | APT 2 | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405021974 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8657765167 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 913 N DIXIE AVE | ||||||||
Address2: |   | ||||||||
City: | ELIZABETHTOWN | ||||||||
State: | KY | ||||||||
PostalCode: | 427012503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8777836257 | ||||||||
FaxNumber: | 8595145521 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2015 | ||||||||
LastUpdateDate: | 02/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2037 | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | PA2037 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.