Provider Demographics
NPI:1073557039
Name:KAISER, KENNETH (NP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:KAISER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4113
Mailing Address - Country:US
Mailing Address - Phone:601-856-2460
Mailing Address - Fax:601-856-4687
Practice Address - Street 1:11 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4113
Practice Address - Country:US
Practice Address - Phone:601-856-2460
Practice Address - Fax:601-856-4687
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR856338363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125332Medicaid
MS202011213AOtherBLUE CROSS
MN00125332Medicaid
MS202011213AOtherBLUE CROSS
MS500001761Medicare PIN
MSCK4239Medicare PIN
MS00125332Medicaid