Provider Demographics
NPI:1225245343
Name:SKINNER, KENTUCKY R (O-PA/C)
Entity Type:Individual
Prefix:MR
First Name:KENTUCKY
Middle Name:R
Last Name:SKINNER
Suffix:
Gender:M
Credentials:O-PA/C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 AUDUBON DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471
Mailing Address - Country:US
Mailing Address - Phone:985-845-1501
Mailing Address - Fax:985-845-1601
Practice Address - Street 1:230 AUDUBON DR
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471
Practice Address - Country:US
Practice Address - Phone:985-845-1501
Practice Address - Fax:985-845-1601
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2008-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACN88759363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LACN88759OtherNC OF ASSIST SURGEONS