Provider Demographics
NPI:1134515083
Name:PENTICUFF, JUSTIN CLAY
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:CLAY
Last Name:PENTICUFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 CHERYL LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2318
Mailing Address - Country:US
Mailing Address - Phone:859-749-0248
Mailing Address - Fax:
Practice Address - Street 1:810 CHERYL LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2318
Practice Address - Country:US
Practice Address - Phone:859-749-0248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY55255208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program