Provider Demographics
NPI:1467028522
Name:SIEVERS, DOUGLAS CADE
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:CADE
Last Name:SIEVERS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:1207 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-258-8575
Practice Address - Fax:859-258-8562
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2823363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100746520Medicaid