Provider Demographics
NPI:1043204126
Name:WILES, KENNA W (PA)
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:W
Last Name:WILES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-2126
Mailing Address - Country:US
Mailing Address - Phone:229-420-0227
Mailing Address - Fax:
Practice Address - Street 1:1009 N MONROE ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1903
Practice Address - Country:US
Practice Address - Phone:229-883-0298
Practice Address - Fax:229-438-7898
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS48756Medicare UPIN
511G701098Medicare PIN