Provider Demographics
NPI:1669042172
Name:PRIME, JONATHAN TUCKER
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TUCKER
Last Name:PRIME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 AXIS DR APT 307
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-0139
Mailing Address - Country:US
Mailing Address - Phone:171-747-5974
Mailing Address - Fax:
Practice Address - Street 1:302 AXIS DR APT 307
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-0139
Practice Address - Country:US
Practice Address - Phone:171-747-5974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY269628213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery