Provider Demographics
NPI:1326877077
Name:FUGATE, AVA CARLISLE (PA-C)
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:CARLISLE
Last Name:FUGATE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLIE
Other - Middle Name:
Other - Last Name:FUGATE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2296 VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-0907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1780 NICHOLASVILLE RD STE 403
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1413
Practice Address - Country:US
Practice Address - Phone:859-260-6348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC14363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant