Provider Demographics
NPI:1073569224
Name:ANDERSON, KENNETH ALLEN (PA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ALLEN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 21ST ST SE APT 22
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-3576
Mailing Address - Country:US
Mailing Address - Phone:912-659-3988
Mailing Address - Fax:
Practice Address - Street 1:1321 N CENTER ST
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-2535
Practice Address - Country:US
Practice Address - Phone:828-322-3898
Practice Address - Fax:828-322-5485
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004563363AS0400X
NC0010-0869363AM0700X
NC0010-00519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA103960745AMedicaid
GAQ50589Medicare UPIN
GA97WCHGTMedicare ID - Type UnspecifiedMEDICARE
NCNC1217AMedicare PIN