Basic Information
| Provider Information | |||||||||
| NPI: | 1073820205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSLEY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALLAN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1595 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411051595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2245 WINCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064082600 | ||||||||
| FaxNumber: | 6064082605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2010 | ||||||||
| LastUpdateDate: | 05/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3006582 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 11772-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P00962937 | 01 | KY | RR MEDICARE | OTHER | P00901248 | 01 | OH | RR MEDICARE | OTHER | 7100144230 | 05 | KY | MEDICAID | 3810019002 | 05 | WV | MEDICAID | 3091032 | 05 | OH | MEDICAID |