Provider Demographics
NPI:1417037052
Name:MANSELLE, KENNETH PAUL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:PAUL
Last Name:MANSELLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4473 EMERSON PARK DR
Mailing Address - Street 2:#101
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-6107
Mailing Address - Country:US
Mailing Address - Phone:941-961-3977
Mailing Address - Fax:
Practice Address - Street 1:1050 W CARROLL ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-1268
Practice Address - Country:US
Practice Address - Phone:407-518-9775
Practice Address - Fax:407-518-0094
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PA9101437363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical