Provider Demographics
NPI:1205139631
Name:THACKER, DANNY W (PA-C)
Entity type:Individual
Prefix:
First Name:DANNY
Middle Name:W
Last Name:THACKER
Suffix:
Gender:M
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-875-9885
Mailing Address - Fax:
Practice Address - Street 1:279 KINGS DAUGHTERS DR
Practice Address - Street 2:SUITE 204
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-6561
Practice Address - Country:US
Practice Address - Phone:502-875-9885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1619363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100293560Medicaid