Provider Demographics
NPI:1447275797
Name:MADDOX, LIBBIA A (PA)
Entity type:Individual
Prefix:MRS
First Name:LIBBIA
Middle Name:A
Last Name:MADDOX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-325-6888
Mailing Address - Fax:606-326-9368
Practice Address - Street 1:617 23RD ST STE 415
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2882
Practice Address - Country:US
Practice Address - Phone:606-325-6888
Practice Address - Fax:606-326-9368
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA589363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100006060Medicaid