Provider Demographics
NPI:1033415203
Name:MIEDEMA, KENDYL WASHBURN (PA)
Entity Type:Individual
Prefix:MRS
First Name:KENDYL
Middle Name:WASHBURN
Last Name:MIEDEMA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KENDYL
Other - Middle Name:
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9601 BAPTIST HEALTH DR STE 860
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6375
Mailing Address - Country:US
Mailing Address - Phone:501-975-7455
Mailing Address - Fax:501-975-3631
Practice Address - Street 1:9601 BAPTIST HEALTH DR STE 860
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6375
Practice Address - Country:US
Practice Address - Phone:501-975-7456
Practice Address - Fax:501-975-1822
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-426363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G214P296Medicare PIN