Basic Information
| Provider Information | |||||||||
| NPI: | 1730739483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUGATE | ||||||||
| FirstName: | WILSON | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 COMMERCE CROSSING, 3RD FLOOR | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402292182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534924 | ||||||||
| FaxNumber: | 5024895750 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 NICHOLASVILLE RD STE 601 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592775887 | ||||||||
| FaxNumber: | 8592767659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2019 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3012571 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.