Basic Information
| Provider Information | |||||||||
| NPI: | 1285156703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUST | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUST | ||||||||
| OtherFirstName: | JASON | ||||||||
| OtherMiddleName: | MICHAEL | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2605 KENTUCKY AVE STE 306 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704157653 | ||||||||
| FaxNumber: | 2705758359 | ||||||||
| Practice Location | |||||||||
| Address1: | 4754 US HIGHWAY 62 | ||||||||
| Address2: | |||||||||
| City: | CALVERT CITY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420298456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704157780 | ||||||||
| FaxNumber: | 2704157779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2017 | ||||||||
| LastUpdateDate: | 07/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3011416 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.