Provider Demographics
NPI:1902973043
Name:HARSTON, PAMELA KAYE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:KAYE
Last Name:HARSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 LYDA AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5829
Mailing Address - Country:US
Mailing Address - Phone:270-904-6160
Mailing Address - Fax:270-904-6165
Practice Address - Street 1:1890 LYDA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5829
Practice Address - Country:US
Practice Address - Phone:270-904-6160
Practice Address - Fax:270-904-6165
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25936208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1157737OtherPASSPORT MEDICAID
KY64259369Medicaid
KY000000197280OtherANTHEM BCBS
KY250005380OtherRR MEDICARE
KY1467280OtherUMWA
KY8122OtherKY DEPT OF WC
KY1157737OtherPASSPORT MEDICAID
KY64259369Medicaid