Provider Demographics
NPI:1194228684
Name:SUPERNOVA, EMILY BUCKMILLER (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:BUCKMILLER
Last Name:SUPERNOVA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4001 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4714
Practice Address - Country:US
Practice Address - Phone:502-559-3930
Practice Address - Fax:502-559-4605
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10732519-1206363A00000X
MO2018013895363A00000X
KYPA2967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA2967OtherSTATE LICENSE