Provider Demographics
NPI:1376260398
Name:PADILLA, KENNETH JACK (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JACK
Last Name:PADILLA
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 1:2700 W MEDILL AVE # G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3053
Mailing Address - Country:US
Mailing Address - Phone:630-863-4397
Mailing Address - Fax:
Practice Address - Street 1:929 W HIGGINS RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60195-3203
Practice Address - Country:US
Practice Address - Phone:847-285-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.009294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant