Individual
LIA BACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
1221 S BROADWAY, LEXINGTON, KY 40504-2701
(859) 258-4000
(859) 258-6203
Mailing address
1221 S BROADWAY, LEXINGTON, KY 40504-2701
(859) 258-6200
(859) 258-6203
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA435
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300026152
—
IN
01
—
412840162
MEDICARE
IN
05
—
7100097340
—
KY
Enumeration date
07/28/2006
Last updated
05/24/2023
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