Provider Demographics
NPI:1548488588
Name:ELLIOTT, ANTHONY WAYNE II (KCSA)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:WAYNE
Last Name:ELLIOTT
Suffix:II
Gender:M
Credentials:KCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 JUSTINIAN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-8630
Mailing Address - Country:US
Mailing Address - Phone:502-523-6317
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:3300 JUSTINIAN
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-8630
Practice Address - Country:US
Practice Address - Phone:502-523-6317
Practice Address - Fax:812-288-1119
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA102246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000628536OtherANTHEM BC/BS