Provider Demographics
NPI:1336233998
Name:COLLETT, DESHANA A (PA-C)
Entity Type:Individual
Prefix:
First Name:DESHANA
Middle Name:A
Last Name:COLLETT
Suffix:
Gender:F
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 1:989 GOVERNORS LN STE 240
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1175
Mailing Address - Country:US
Mailing Address - Phone:859-338-3958
Mailing Address - Fax:859-368-8135
Practice Address - Street 1:989 GOVERNORS LN STE 240
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1175
Practice Address - Country:US
Practice Address - Phone:859-338-3958
Practice Address - Fax:859-368-8135
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA845363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95004800Medicaid
KY37903705OtherMEDICAID LAB GROUP
KY95004800Medicaid
GAP00155603OtherRR MEDICARE PIN
KY4000501OtherMEDICARE LAB GROUP
KY0225321Medicare ID - Type Unspecified
KY37903705OtherMEDICAID LAB GROUP