Provider Demographics
NPI:1962568444
Name:AGLE, TRISHA JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:JEAN
Last Name:AGLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:502-363-0588
Mailing Address - Fax:502-363-0972
Practice Address - Street 1:4402 CHURCHMAN AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1190
Practice Address - Country:US
Practice Address - Phone:502-363-0588
Practice Address - Fax:502-363-0972
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04863363AM0700X
NC0010-02273363A00000X
KYPA1801363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04863OtherSTATE BOARD LICENSE NO.
KY7100252770Medicaid
NC0010-02273OtherNCMB
KYK092470Medicare PIN
TXPA04863OtherSTATE BOARD LICENSE NO.