Provider Demographics
NPI:1649568312
Name:EXCELLENT PROFESSIONAL ANES., PLLC
Entity Type:Organization
Organization Name:EXCELLENT PROFESSIONAL ANES., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:P
Authorized Official - Last Name:AYO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:270-362-9480
Mailing Address - Street 1:659 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GILBERTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42044-8666
Mailing Address - Country:US
Mailing Address - Phone:270-362-9480
Mailing Address - Fax:574-268-0684
Practice Address - Street 1:803 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2432
Practice Address - Country:US
Practice Address - Phone:270-762-1104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-15
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74008046Medicaid
KYK061490Medicare PIN