Provider Demographics
NPI:1407812340
Name:ELBERT, BRUCE (PA)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:ELBERT
Suffix:
Gender:M
Credentials:PA
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 4168
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601
Mailing Address - Country:US
Mailing Address - Phone:502-223-5811
Mailing Address - Fax:502-227-7379
Practice Address - Street 1:4 HMB CIRCLE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601
Practice Address - Country:US
Practice Address - Phone:502-695-7725
Practice Address - Fax:502-695-7848
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA527363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0404720Medicare PIN
S96263Medicare UPIN