Provider Demographics
NPI:1144736679
Name:THIRY, JACQUELINE M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:M
Last Name:THIRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQULINE
Other - Middle Name:MARIE
Other - Last Name:HOESEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:218 S. MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391
Mailing Address - Country:US
Mailing Address - Phone:859-745-2861
Mailing Address - Fax:859-745-1978
Practice Address - Street 1:218 S. MAPLE ST.
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391
Practice Address - Country:US
Practice Address - Phone:859-745-2861
Practice Address - Fax:859-745-1978
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111189363A00000X
KYPA2717363AM0700X, 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
KY7100738410Medicaid