Provider Demographics
NPI:1235240557
Name:FARRELL, KENNETH WAYNE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WAYNE
Last Name:FARRELL
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 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4439
Mailing Address - Fax:
Practice Address - Street 1:5881 W 16TH ST STE A
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-2910
Practice Address - Country:US
Practice Address - Phone:970-652-2454
Practice Address - Fax:970-652-2447
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16558OtherPHYSICIAN ASSISTANT BOARD
CAWPA16558BMedicare ID - Type Unspecified