Basic Information
Provider Information
NPI: 1003151150
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WOLFE
FirstName: KEVIN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: APRN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 2379
Address2:  
City: ASHLAND
State: KY
PostalCode: 411052379
CountryCode: US
TelephoneNumber: 6064086200
FaxNumber: 6064086612
Practice Location
Address1: 2001 SCIOTO TRL
Address2: STE 200
City: PORTSMOUTH
State: OH
PostalCode: 456622845
CountryCode: US
TelephoneNumber: 7403538100
FaxNumber: 7403538908
Other Information
ProviderEnumerationDate: 11/30/2012
LastUpdateDate: 10/26/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X13506-NPOHY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
363LF0000X3007555KYN Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

ID Information
IDTypeStateIssuerDescription
008355205OH MEDICAID
381002585705WV MEDICAID
710024109005KY MEDICAID


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