| Doctor Name: | CHARLES CUSUMANO |
| NPI Number: | 1194723445 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | FMP, PA-C |
| License Number: | KY PA 203 |
| Business Practice Address: | 150 W Bear Track Rd Campbellsville, KY - 427188709 |
| Business Phone Number: | 2704658133 |
| Business Fax Number: | 2707891543 |
| Mailing Address: | 804 Lebanon Ave, CAMPBELLSVILLE |
| State: | KY |
| Postal Code: | 427181810 |
| Phone Number: | 2707892579 |
| Fax Number: | 2707890290 |
| NPI Enumeration Date: | 07/11/2005 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | KY PA 203 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | KY |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |