Provider Demographics
NPI:1083674097
Name:KENNEDY, ANDRA R (PA)
Entity Type:Individual
Prefix:
First Name:ANDRA
Middle Name:R
Last Name:KENNEDY
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 1:5900 NW 86TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2284
Mailing Address - Country:US
Mailing Address - Phone:515-276-6133
Mailing Address - Fax:515-334-7356
Practice Address - Street 1:5900 NW 86TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-2284
Practice Address - Country:US
Practice Address - Phone:515-276-6133
Practice Address - Fax:515-334-7356
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA648363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS65641Medicare UPIN