Provider Demographics
NPI:1619010444
Name:FIESSINGER, WILLARD JASON (APRN)
Entity type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:JASON
Last Name:FIESSINGER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 WELLNESS WAY STE 101&201
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-7156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:83 WELLNESS WAY STE 101&201
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-7156
Practice Address - Country:US
Practice Address - Phone:270-527-0045
Practice Address - Fax:270-527-0075
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005118363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000602049OtherBCBS
KY7100052530Medicaid
KYK026320Medicare PIN
KYK026320Medicare PIN
KYP00734653Medicare PIN
KY00223003Medicare PIN