Provider Demographics
NPI:1154767960
Name:ODOM, CAITLIN (PA-C)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:
Other - Last Name:MICHALAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 E COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-2814
Mailing Address - Country:US
Mailing Address - Phone:734-478-9611
Mailing Address - Fax:
Practice Address - Street 1:1111 MEDICAL CENTER CIR
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1194
Practice Address - Country:US
Practice Address - Phone:270-251-4527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107229363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01204898OtherR&R MEDICARE
FLP01204898OtherR&R MEDICARE