Provider Demographics
NPI:1629272901
Name:STRADER, JANE WISEMAN (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:WISEMAN
Last Name:STRADER
Suffix:
Gender:F
Credentials:MD
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 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-408-4000
Mailing Address - Fax:
Practice Address - Street 1:1109 BELLEFONTE RD
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:KY
Practice Address - Zip Code:41139-2503
Practice Address - Country:US
Practice Address - Phone:606-836-8086
Practice Address - Fax:606-836-3743
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35096112207Q00000X
KY43728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3083292Medicaid
KY7100132920Medicaid
OH3083292Medicaid
KY7100132920Medicaid