Provider Demographics
NPI:1114994001
Name:RHODES, ADA M (PA - C)
Entity Type:Individual
Prefix:
First Name:ADA
Middle Name:M
Last Name:RHODES
Suffix:
Gender:F
Credentials:PA - C
Other - Prefix:
Other - First Name:ADA
Other - Middle Name:M
Other - Last Name:WILLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:2211 MAYFAIR DR
Practice Address - Street 2:SUITE 101
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4568
Practice Address - Country:US
Practice Address - Phone:270-688-1352
Practice Address - Fax:270-683-4313
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100100730Medicaid
KY3397797Medicare PIN
S46782Medicare UPIN
KY000000635812OtherANTHEM # WITH CHS, INC.
970029793Medicare ID - Type UnspecifiedRR MEDICARE
KY0744404Medicare ID - Type Unspecified