Provider Demographics
NPI:1205189404
Name:CAUDILL, JEREMY DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:CAUDILL
Suffix:
Gender:M
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 1:333 S 3RD ST
Mailing Address - Street 2:STE B
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2016
Mailing Address - Country:US
Mailing Address - Phone:859-236-8730
Mailing Address - Fax:859-236-4468
Practice Address - Street 1:333 S 3RD ST
Practice Address - Street 2:STE B
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2016
Practice Address - Country:US
Practice Address - Phone:859-236-8730
Practice Address - Fax:859-236-4468
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant