Provider Demographics
NPI:1720340375
Name:MYERS, ALICIA D (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:D
Last Name:MYERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:D
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:509 MEMORIAL DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6195
Mailing Address - Country:US
Mailing Address - Phone:606-598-5104
Mailing Address - Fax:606-598-0983
Practice Address - Street 1:65 GLENNDALE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6212
Practice Address - Country:US
Practice Address - Phone:606-599-2508
Practice Address - Fax:606-599-2507
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
K058810Medicare PIN