Provider Demographics
NPI:1780837062
Name:BLUEGRASS REGIONAL FOOT & ANKLE ASSOCIATES
Entity Type:Organization
Organization Name:BLUEGRASS REGIONAL FOOT & ANKLE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:K
Authorized Official - Last Name:KRESTIK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:606-862-9900
Mailing Address - Street 1:1105 W 5TH ST
Mailing Address - Street 2:#3
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-1610
Mailing Address - Country:US
Mailing Address - Phone:606-862-9900
Mailing Address - Fax:606-862-8901
Practice Address - Street 1:1105 W 5TH ST
Practice Address - Street 2:#3
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-1610
Practice Address - Country:US
Practice Address - Phone:606-862-9900
Practice Address - Fax:606-862-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5140P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY=========OtherTAX ID