Provider Demographics
NPI:1538254610
Name:CLEARY, JUDITH LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:LYNN
Last Name:CLEARY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 WOODCREST DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-9764
Mailing Address - Country:US
Mailing Address - Phone:859-223-4709
Mailing Address - Fax:
Practice Address - Street 1:700 BOB O LINK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3756
Practice Address - Country:US
Practice Address - Phone:859-258-8530
Practice Address - Fax:859-258-8515
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA641363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95001772Medicaid
KY95001772Medicaid
P35727Medicare UPIN