Provider Demographics
NPI:1306412960
Name:HALL, FALLON SMITH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:FALLON
Middle Name:SMITH
Last Name:HALL
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 1:148 SKYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1496
Mailing Address - Country:US
Mailing Address - Phone:859-499-0717
Mailing Address - Fax:859-499-0926
Practice Address - Street 1:148 SKYVIEW DR
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1496
Practice Address - Country:US
Practice Address - Phone:859-499-0717
Practice Address - Fax:859-499-0926
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA3011363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100949250Medicaid