Provider Demographics
NPI:1861497661
Name:KONDIK, GEORGE AVERY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:AVERY
Last Name:KONDIK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-301-0655
Practice Address - Street 1:2845 CHANCELLOR DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3418
Practice Address - Country:US
Practice Address - Phone:859-426-4200
Practice Address - Fax:859-426-4206
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA568363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCB8861OtherRAILROAD MEDICARE
KY000000241201OtherANTHEM
KY90008962OtherMEDICAID DME
KY970027844OtherRAILROAD MEDICARE
KY428850003OtherMEDICARE DME
KY95001970Medicaid
KYCB8861OtherRAILROAD MEDICARE
KY0389214Medicare PIN