Provider Demographics
NPI:1346496866
Name:WAUGH, KENNETH G (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:G
Last Name:WAUGH
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:PO BOX 651
Mailing Address - Street 2:
Mailing Address - City:GIRDWOOD
Mailing Address - State:AK
Mailing Address - Zip Code:99587-0651
Mailing Address - Country:US
Mailing Address - Phone:907-783-2311
Mailing Address - Fax:
Practice Address - Street 1:131 LINBLAD AVE.
Practice Address - Street 2:
Practice Address - City:GIRDWOOD
Practice Address - State:AK
Practice Address - Zip Code:99587
Practice Address - Country:US
Practice Address - Phone:907-783-2311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK507363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical