Provider Demographics
NPI:1730739483
Name:FUGATE, WILSON BRADLEY (APRN)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:BRADLEY
Last Name:FUGATE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 COMMERCE CROSSING, 3RD FLOOR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:1720 NICHOLASVILLE RD STE 601
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1451
Practice Address - Country:US
Practice Address - Phone:859-277-5887
Practice Address - Fax:859-276-7659
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily