Provider Demographics
NPI:1043232689
Name:KENNY, MATTHEW P (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:KENNY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 W WACKERLY ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4724
Mailing Address - Country:US
Mailing Address - Phone:989-839-8824
Mailing Address - Fax:989-835-3398
Practice Address - Street 1:728 W WACKERLY ST STE 100
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4724
Practice Address - Country:US
Practice Address - Phone:989-839-8824
Practice Address - Fax:989-835-3398
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004770363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE66019098OtherMEDICARE PTAN
MIZ96017107OtherMEDICARE PTAN