Provider Demographics
NPI:1225390891
Name:TUCKER, KAITLYN DIANE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:DIANE
Last Name:TUCKER
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-587-6010
Mailing Address - Fax:
Practice Address - Street 1:6400 DUTCHMANS PKWY STE 345
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3370
Practice Address - Country:US
Practice Address - Phone:502-587-6010
Practice Address - Fax:502-587-1314
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363A00000X
GA006465207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant