Provider Demographics
NPI:1831285477
Name:ANTLE, AMY (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ANTLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 N EAGLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2121
Mailing Address - Country:US
Mailing Address - Phone:859-263-0022
Mailing Address - Fax:859-263-4666
Practice Address - Street 1:160 N EAGLE CREEK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2121
Practice Address - Country:US
Practice Address - Phone:859-263-0022
Practice Address - Fax:859-263-4666
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA 118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000374870OtherANTHEM
KY95000758Medicaid
KY95000758Medicaid