Provider Demographics
NPI:1043305477
Name:KALLMAN, JAMIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:A
Last Name:KALLMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:A
Other - Last Name:QUALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 ELAINE DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2754
Mailing Address - Country:US
Mailing Address - Phone:859-258-4508
Mailing Address - Fax:859-258-6122
Practice Address - Street 1:100 NORTH EAGLE CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509
Practice Address - Country:US
Practice Address - Phone:859-258-5102
Practice Address - Fax:859-258-5177
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA506363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0169OtherMEDICARE GROUP ID
KYCB 5773OtherRR MEDICARE GROUP#
KY4000501OtherMEDICARE LAB GROUP#
KY970021224OtherRR MEDICARE PIN#
KY37903705OtherMEDICAID LAB GROUP#
KY95000212Medicaid
P29656Medicare UPIN
KY00637035Medicare PIN
KY95000212Medicaid