Provider Demographics
NPI:1508320078
Name:HERNDON, HALEY (PA-C)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:HERNDON
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 1:5050 VILLAGE SQUARE DR STE B
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7552
Mailing Address - Country:US
Mailing Address - Phone:270-534-5128
Mailing Address - Fax:270-477-0007
Practice Address - Street 1:2327 NEW HOLT RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7404
Practice Address - Country:US
Practice Address - Phone:270-534-5128
Practice Address - Fax:270-477-0007
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2023-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2476363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA2476OtherKENTUCKY BOARD OF MEDICAL LICENSURE