Basic Information
| Provider Information | |||||||||
| NPI: | 1689641011 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARAH | ||||||||
| FirstName: | IAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 909 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028528266 | ||||||||
| FaxNumber: | 5028523726 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028528266 | ||||||||
| FaxNumber: | 5028523726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 09/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 3003784 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 1098104 | KY | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 74012048 | 05 | KY | MEDICAID |