Provider Demographics
NPI:1043465164
Name:HARDESTY, MYRON JEFFREY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MYRON
Middle Name:JEFFREY
Last Name:HARDESTY
Suffix:
Gender:M
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 1:7505 NEW LAGRANGE ROAD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222
Mailing Address - Country:US
Mailing Address - Phone:502-412-3232
Mailing Address - Fax:502-412-3233
Practice Address - Street 1:7505 NEW LAGRANGE ROAD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222
Practice Address - Country:US
Practice Address - Phone:502-412-3232
Practice Address - Fax:502-412-3233
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1185363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY11918387OtherCAQH
KY11918387OtherCAQH