Provider Demographics
NPI:1124226568
Name:SMITH, KENNETH L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:L
Last Name:SMITH
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 1:4208 FAIRFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3628
Mailing Address - Country:US
Mailing Address - Phone:706-650-9552
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:NEPHROLOGY DIVISION, MEDICAL COLLEGE OF GA, BA-9413
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-2861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000725363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical