Provider Demographics
NPI:1073662664
Name:DIPPEL, KENNETH NEIL (PA -C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:NEIL
Last Name:DIPPEL
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 1:811 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-2735
Mailing Address - Country:US
Mailing Address - Phone:304-346-4311
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVE. SE
Practice Address - Street 2:CAMC MEMORIAL HOSPITAL
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-8199
Practice Address - Fax:304-388-8195
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00710363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVS95969Medicare UPIN
DIPA79031Medicare ID - Type Unspecified