Basic Information
| Provider Information | |||||||||
| NPI: | 1295734747 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOUGNIE | ||||||||
| FirstName: | KIRK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4331 CHURCHMAN AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402151164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023640902 | ||||||||
| FaxNumber: | 5023640099 | ||||||||
| Practice Location | |||||||||
| Address1: | 4331 CHURCHMAN AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402151164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023640902 | ||||||||
| FaxNumber: | 5023640099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 10/19/2015 | ||||||||
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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 | 363A00000X | PA582 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 95001475 | 05 | KY | MEDICAID | 50019798 | 01 | KY | PASSPORT HEALTH PLAN | OTHER |