Basic Information
Provider Information | |||||||||
NPI: | 1578821393 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STUCKER | ||||||||
FirstName: | ANDREA | ||||||||
MiddleName: | HALE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5200 COMMERCE CROSSINGS DR | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402292182 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022534900 | ||||||||
FaxNumber: | 5024895751 | ||||||||
Practice Location | |||||||||
Address1: | 3615 E JOHN ROWAN BLVD STE 203 | ||||||||
Address2: |   | ||||||||
City: | BARDSTOWN | ||||||||
State: | KY | ||||||||
PostalCode: | 400043265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5023376815 | ||||||||
FaxNumber: | 5023571682 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/30/2012 | ||||||||
LastUpdateDate: | 12/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1721 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 7100212110 | 05 | KY |   | MEDICAID | PA1721 | 01 | KY | MEDICAL LICENSE | OTHER |