Provider Demographics
NPI:1295734747
Name:FOUGNIE, KIRK A (PA-C)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:A
Last Name:FOUGNIE
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 1:4331 CHURCHMAN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1164
Mailing Address - Country:US
Mailing Address - Phone:502-364-0902
Mailing Address - Fax:502-364-0099
Practice Address - Street 1:4331 CHURCHMAN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1164
Practice Address - Country:US
Practice Address - Phone:502-364-0902
Practice Address - Fax:502-364-0099
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA582363A00000X, 207X00000X
IN10000486A207Y00000X, 207X00000X
KYPA1131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95001475Medicaid
KY50019798OtherPASSPORT HEALTH PLAN
KY50019798OtherPASSPORT HEALTH PLAN
KY0945604Medicare PIN
ININ2105003Medicare PIN