Provider Demographics
NPI:1679926448
Name:DICK, DONALD EMERSON
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:EMERSON
Last Name:DICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 W LINCOLN TRAIL BLVD
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-2681
Mailing Address - Country:US
Mailing Address - Phone:502-492-1664
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:650 W LINCOLN TRAIL BLVD STE B
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-2681
Practice Address - Country:US
Practice Address - Phone:270-352-4601
Practice Address - Fax:270-352-4600
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant