Provider Demographics
NPI:1790759314
Name:MENIKOFF, DEANA M (PA-C)
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:M
Last Name:MENIKOFF
Suffix:
Gender:F
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 1:220 ABRAHAM FLEXNER WAY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3826
Mailing Address - Country:US
Mailing Address - Phone:502-584-3376
Mailing Address - Fax:502-584-1385
Practice Address - Street 1:220 ABRAHAM FLEXNER WAY
Practice Address - Street 2:SUITE 500
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3826
Practice Address - Country:US
Practice Address - Phone:502-584-3376
Practice Address - Fax:502-584-1385
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA551363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1130973OtherPASSPORT
KY9500112900Medicaid
KY2437660000OtherPASSPORT ADVANTAGE
KY000000190242OtherANTHEM PROVIDER #
KY000000190242OtherANTHEM PROVIDER #
KY1130973OtherPASSPORT