Provider Demographics
NPI:1780139295
Name:JEFFRIES, NATALIE WISE (PA-C)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:WISE
Last Name:JEFFRIES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:D
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4331 CHURCHMAN AVE
Mailing Address - Street 2:STE 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:STE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215
Practice Address - Country:US
Practice Address - Phone:502-364-0902
Practice Address - Fax:502-364-0099
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100437600Medicaid
KY000001040338OtherANTHEM
KY7100437600Medicaid