Individual
STAG BLAIR SHADDUCK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
560 S LOOP RD, EDGEWOOD, KY 41017-3405
(859) 301-2663
(859) 817-7848
Mailing address
560 S LOOP RD, EDGEWOOD, KY 41017-3405
(859) 301-2663
(859) 817-7848
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
TC072
KY
Other
Enumeration date
01/27/2021
Last updated
08/18/2021
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