Provider Demographics
NPI:1417045857
Name:FLECK, KENNETH LEO (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEO
Last Name:FLECK
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 1:5012 161ST ST E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98446-3810
Mailing Address - Country:US
Mailing Address - Phone:253-536-1232
Mailing Address - Fax:253-536-9028
Practice Address - Street 1:910 TACOMA AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-2104
Practice Address - Country:US
Practice Address - Phone:253-708-4033
Practice Address - Fax:253-798-4043
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001613363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB36263Medicaid
WAGAB36263Medicaid
WAGAB36263Medicare ID - Type Unspecified