Provider Demographics
NPI:1477168169
Name:AMMERMAN, ELESHIA STEPHENIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELESHIA
Middle Name:STEPHENIE
Last Name:AMMERMAN
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 1:343 HARNESS RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-8874
Mailing Address - Country:US
Mailing Address - Phone:606-312-6989
Mailing Address - Fax:
Practice Address - Street 1:60 BRYAN BLVD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2779
Practice Address - Country:US
Practice Address - Phone:606-528-1172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100727050Medicaid