Provider Demographics
NPI: | 1619010444 |
---|---|
Name: | FIESSINGER, WILLARD JASON (APRN) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | WILLARD |
Middle Name: | JASON |
Last Name: | FIESSINGER |
Suffix: | |
Gender: | M |
Credentials: | APRN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 83 WELLNESS WAY STE 101&201 |
Mailing Address - Street 2: | |
Mailing Address - City: | BENTON |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 42025-7156 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 83 WELLNESS WAY STE 101&201 |
Practice Address - Street 2: | |
Practice Address - City: | BENTON |
Practice Address - State: | KY |
Practice Address - Zip Code: | 42025-7156 |
Practice Address - Country: | US |
Practice Address - Phone: | 270-527-0045 |
Practice Address - Fax: | 270-527-0075 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-02-14 |
Last Update Date: | 2023-12-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | 3005118 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 000000602049 | Other | BCBS |
KY | 7100052530 | Medicaid | |
KY | K026320 | Medicare PIN | |
KY | K026320 | Medicare PIN | |
KY | P00734653 | Medicare PIN | |
KY | 00223003 | Medicare PIN |