Provider Demographics
NPI:1134140494
Name:RAISLEY, JENNIFER A (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:RAISLEY
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 1:740 S LIMESTONE
Mailing Address - Street 2:K401
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:859-323-5533
Mailing Address - Fax:859-323-2412
Practice Address - Street 1:740 S LIMESTONE
Practice Address - Street 2:K401
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-5533
Practice Address - Fax:859-323-2412
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA993363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100003050Medicaid
KY000000494035OtherBLUE CROSS BLUE SHIELD
KY61-0979936OtherTAX ID
KY1207909Medicare PIN
KY61-0979936OtherTAX ID