Provider Demographics
NPI:1083898290
Name:KENNEDY, WARREN K (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WARREN
Middle Name:K
Last Name:KENNEDY
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 1:3420 ILLINOIS STREET
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:ID
Mailing Address - Zip Code:60088-1312
Mailing Address - Country:US
Mailing Address - Phone:847-688-2522
Mailing Address - Fax:
Practice Address - Street 1:3420 ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-3120
Practice Address - Country:US
Practice Address - Phone:847-688-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical