Provider Demographics
NPI:1629487301
Name:RUTHERFORD, ANDREW C (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:C
Last Name:RUTHERFORD
Suffix:
Gender:M
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 1:4208 VICTORIA WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-4822
Mailing Address - Country:US
Mailing Address - Phone:270-522-3444
Mailing Address - Fax:
Practice Address - Street 1:250 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211-9153
Practice Address - Country:US
Practice Address - Phone:270-522-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1945363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA1945OtherSTATE LICENSE
1120392OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS