Provider Demographics
NPI:1083769681
Name:BRANSTETTER, GREGORY (CST,CFA,KCSA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BRANSTETTER
Suffix:
Gender:M
Credentials:CST,CFA,KCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 COLUMNS PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-8068
Mailing Address - Country:US
Mailing Address - Phone:270-651-9390
Mailing Address - Fax:270-651-8698
Practice Address - Street 1:106 COLUMNS PLAZA DR
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-8068
Practice Address - Country:US
Practice Address - Phone:270-651-9390
Practice Address - Fax:270-651-8698
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY82418363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00F817OtherCERTIFIED FIRST ASSISTANT