Provider Demographics
NPI:1154654218
Name:CLEVENGER, KENDALL (PA)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:CLEVENGER
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 1:13709 BISTRAM RD
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-7237
Mailing Address - Country:US
Mailing Address - Phone:715-463-3816
Mailing Address - Fax:
Practice Address - Street 1:510 2ND ST SE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1706
Practice Address - Country:US
Practice Address - Phone:320-629-6721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant