Provider Demographics
NPI:1164583092
Name:KENNEDY, SEAN M (PA-C)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:M
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 1:39400 PASEO PADRE PKWY
Mailing Address - Street 2:SURGERY DEPT - EMBARCADERO BLDG
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-2310
Mailing Address - Country:US
Mailing Address - Phone:510-248-3075
Mailing Address - Fax:510-248-3364
Practice Address - Street 1:39400 PASEO PADRE PKWY
Practice Address - Street 2:SURGERY DEPT - EMBARCADERO BLDG
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2310
Practice Address - Country:US
Practice Address - Phone:510-248-3075
Practice Address - Fax:510-248-3364
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16076363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical