Provider Demographics
NPI:1164613592
Name:KENNEDY, EVAN PAUL (PA-C)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:PAUL
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:2960 E MARKET ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-2414
Practice Address - Country:US
Practice Address - Phone:717-751-2483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA-053002363AM0700X
PAOA002796363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA327079YUNMMedicare PIN
PA232759Medicare PIN
PA316090YEBKMedicare PIN