Provider Demographics
NPI:1467450858
Name:HARGIS, ANISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:HARGIS
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 1:301 C MIDDLETON PARK PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243
Mailing Address - Country:US
Mailing Address - Phone:502-244-9858
Mailing Address - Fax:502-244-9575
Practice Address - Street 1:301 C MIDDLETON PARK PL
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243
Practice Address - Country:US
Practice Address - Phone:502-244-9858
Practice Address - Fax:502-244-9575
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA 353363AM0700X
KYPA3532080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000246339OtherANTHEM
KY0789302Medicare ID - Type Unspecified
789302Medicare PIN
KY000000246339OtherANTHEM