Provider Demographics
NPI:1629246889
Name:RUEFF, MARYSA BRAYE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARYSA
Middle Name:BRAYE
Last Name:RUEFF
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 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:250 FOUNTAIN CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1888
Practice Address - Country:US
Practice Address - Phone:859-263-4444
Practice Address - Fax:859-977-2303
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1122363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
C60350OtherCUMBERLAND HEALTHCARE
KY000000552175OtherANTHEM BLUE CROSS & BLUE SHIELD
KY7100110660Medicaid
KY000000552175OtherANTHEM BLUE CROSS & BLUE SHIELD
KYP00718588Medicare PIN