Provider Demographics
NPI:1023566817
Name:PACKER, KENDAL
Entity Type:Individual
Prefix:
First Name:KENDAL
Middle Name:
Last Name:PACKER
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 1:4220 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-5124
Mailing Address - Country:US
Mailing Address - Phone:602-889-9401
Mailing Address - Fax:602-889-9404
Practice Address - Street 1:3306 W ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009-3404
Practice Address - Country:US
Practice Address - Phone:602-278-4930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ194890OtherMEDICARE
AZ184512Medicaid