Provider Demographics
NPI:1619396439
Name:GROSSMAN, AUDRA ISAAC
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:ISAAC
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 HARRODSBURG RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2112
Mailing Address - Country:US
Mailing Address - Phone:859-278-9492
Mailing Address - Fax:859-277-3027
Practice Address - Street 1:2424 HARRODSBURG RD STE 200
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503
Practice Address - Country:US
Practice Address - Phone:859-278-9492
Practice Address - Fax:859-277-3027
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50614207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology