Provider Demographics
NPI:1629073093
Name:GAINES, MARLON (PA)
Entity Type:Individual
Prefix:DR
First Name:MARLON
Middle Name:
Last Name:GAINES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0008
Mailing Address - Country:US
Mailing Address - Phone:800-476-8646
Mailing Address - Fax:919-382-3210
Practice Address - Street 1:727 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1660
Practice Address - Country:US
Practice Address - Phone:502-647-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA076363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYS94236Medicare UPIN
KY0512324Medicare ID - Type UnspecifiedMEDICARE GROUP # 5123