Basic Information
| Provider Information | |||||||||
| NPI: | 1386795425 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAPUTO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LINDA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18320 CHERRYWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | CATLETTSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411294210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707820434 | ||||||||
| FaxNumber: | 2707820564 | ||||||||
| Practice Location | |||||||||
| Address1: | 1945 SCOTTSVILLE RD | ||||||||
| Address2: | B2 PMB 137 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707820434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | SA007 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 007 | 01 | KY | KCSA | OTHER |