Provider Demographics
NPI:1407844087
Name:BEADLE, KENNETH LEE (DSC, PA-C)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:BEADLE
Suffix:
Gender:M
Credentials:DSC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549TH HC/BAACH
Mailing Address - Street 2:UNIT 15245
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96251-5245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:549TH HC/BAACH
Practice Address - Street 2:UNIT 15245
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271
Practice Address - Country:US
Practice Address - Phone:315-757-3536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-08
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108590363A00000X
TXPA08690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant