Basic Information
| Provider Information | |||||||||
| NPI: | 1780641415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KALTENBACH | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2828 1ST AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045256905 | ||||||||
| FaxNumber: | 3045254316 | ||||||||
| Practice Location | |||||||||
| Address1: | 613 23RD ST STE G30 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063270036 | ||||||||
| FaxNumber: | 6063270036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 04/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 943 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 00943 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 50.001490 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA1816 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 7100191670 | 05 | KY | MEDICAID |