Basic Information
| Provider Information | |||||||||
| NPI: | 1407219587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | GREGORY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1000 S 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420719303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707599200 | ||||||||
| FaxNumber: | 2707599966 | ||||||||
| Practice Location | |||||||||
| Address1: | 1212 S WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283401848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106286711 | ||||||||
| FaxNumber: | 9106285735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2884 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0010-06362 | 01 | NC | NC MEDICAL LICENSE | OTHER |