Provider Demographics
NPI:1447484118
Name:ADVANCED SPINE & JOINT
Entity type:Organization
Organization Name:ADVANCED SPINE & JOINT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:270-534-4803
Mailing Address - Street 1:2404 NEW HOLT RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001
Mailing Address - Country:US
Mailing Address - Phone:270-534-4803
Mailing Address - Fax:270-534-4024
Practice Address - Street 1:2404 NEW HOLT RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001
Practice Address - Country:US
Practice Address - Phone:270-534-4803
Practice Address - Fax:270-534-4024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3142P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UP16698Medicare UPIN
KY0128Medicare PIN