Provider Demographics
NPI:1386695419
Name:BLACK, JAMIE (PA-C)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1720 NICHOLASVILLE RD
Mailing Address - Street 2:SUITE 502
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1475
Mailing Address - Country:US
Mailing Address - Phone:859-277-7129
Mailing Address - Fax:859-277-9613
Practice Address - Street 1:1720 NICHOLASVILLE RD
Practice Address - Street 2:SUITE 502
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1475
Practice Address - Country:US
Practice Address - Phone:859-277-7129
Practice Address - Fax:859-277-9613
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYPA690363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP47738Medicare UPIN
KY1267231Medicare ID - Type Unspecified