Provider Demographics
NPI:1255317640
Name:KENNEDY, CHRISTOPHER ANDREW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:ANDREW
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1249 15TH STREET
Mailing Address - Street 2:SUITE 4093
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3662
Mailing Address - Country:US
Mailing Address - Phone:304-691-6800
Mailing Address - Fax:304-691-6751
Practice Address - Street 1:300 CORPORATE CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560
Practice Address - Country:US
Practice Address - Phone:304-691-6800
Practice Address - Fax:304-691-6751
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV01012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006501Medicaid
WVP95255Medicare UPIN
WV3810006501Medicaid