Basic Information
| Provider Information | |||||||||
| NPI: | 1982016630 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIDDLETON | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | BRIAN | ||||||||
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| Credential: | APRN-FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1774 SPILLMAN RD | ||||||||
| Address2: | |||||||||
| City: | CAVE CITY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421279128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705375451 | ||||||||
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| Practice Location | |||||||||
| Address1: | 310 N L ROGER WLS BLVD | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421411300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706595555 | ||||||||
| FaxNumber: | 2706595566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2014 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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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 | 363L00000X | 3008673 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3008673 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P01345178 | 01 | RAILROAD MEDICARE | OTHER | 000000879197 | 01 | KY | ANTHEM | OTHER | 7100299500 | 05 | KY | MEDICAID |