Provider Demographics
NPI:1790763449
Name:PAYNE, GERALD E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:E
Last Name:PAYNE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:GERRY
Other - Middle Name:
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2465 WOODFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-1224
Mailing Address - Country:US
Mailing Address - Phone:859-272-7573
Mailing Address - Fax:
Practice Address - Street 1:286 US HIGHWAY 23 N
Practice Address - Street 2:SUITE 102
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-8732
Practice Address - Country:US
Practice Address - Phone:606-874-0032
Practice Address - Fax:606-874-0064
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA406363A00000X, 363AM0700X
PA406363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002226Medicaid
P33642Medicare UPIN
KY0692912Medicare ID - Type Unspecified
KY0693012Medicare ID - Type Unspecified
KY95002226Medicaid