Provider Demographics
NPI:1508257783
Name:BARTRAM, MALLORY L (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:L
Last Name:BARTRAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:L
Other - Last Name:BUCKOSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:MS-463
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0202
Mailing Address - Country:US
Mailing Address - Phone:859-323-0100
Mailing Address - Fax:859-257-6066
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:MS-463
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0202
Practice Address - Country:US
Practice Address - Phone:859-323-0100
Practice Address - Fax:859-257-6066
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1985363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK119550Medicare PIN