Provider Demographics
NPI:1376702654
Name:RICKEY, CHARLES CHRISTIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CHRISTIAN
Last Name:RICKEY
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 1:379 ASHLEY ST
Mailing Address - Street 2:
Mailing Address - City:FLEMINGSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41041-8777
Mailing Address - Country:US
Mailing Address - Phone:606-615-3265
Mailing Address - Fax:
Practice Address - Street 1:265 BROOKVIEW CENTRE WAY STE 400
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4052
Practice Address - Country:US
Practice Address - Phone:865-293-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA 837363AM0700X
KYKY PA 837363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical