Basic Information
| Provider Information | |||||||||
| NPI: | 1811484389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONDON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1306 VERSAILLES RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592592635 | ||||||||
| FaxNumber: | 8592547874 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 VERSAILLES RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592592635 | ||||||||
| FaxNumber: | 8592547874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2212 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.