Provider Demographics
NPI:1780641415
Name:KALTENBACH, JEREMY M (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:M
Last Name:KALTENBACH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 1ST AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1236
Mailing Address - Country:US
Mailing Address - Phone:304-525-6905
Mailing Address - Fax:304-525-4316
Practice Address - Street 1:613 23RD ST STE G30
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2881
Practice Address - Country:US
Practice Address - Phone:606-327-0036
Practice Address - Fax:606-327-0036
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV943363A00000X
WV00943363AM0700X
OH50.001490363AM0700X
KYPA1816363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100191670Medicaid
WV1699732214OtherGROUP NPI
OHKAPA15583Medicare PIN
WVKAPA15582Medicare PIN
WV0374350001Medicare NSC