Provider Demographics
NPI:1245391473
Name:KENNEDY, MICHAEL ARTHUR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ARTHUR
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 1:1038 ADDISON AVE
Mailing Address - Street 2:
Mailing Address - City:POTTSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75076-7077
Mailing Address - Country:US
Mailing Address - Phone:903-786-8916
Mailing Address - Fax:
Practice Address - Street 1:111 E HWY 120
Practice Address - Street 2:STE. 104
Practice Address - City:POTTSBORO
Practice Address - State:TX
Practice Address - Zip Code:75076-3008
Practice Address - Country:US
Practice Address - Phone:903-786-3911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04828363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical