Provider Demographics
NPI:1417538117
Name:ZACCHEO, KENNEDY M (PA)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:M
Last Name:ZACCHEO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:265 CLARENDON ST APT 4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2012
Mailing Address - Country:US
Mailing Address - Phone:775-200-4961
Mailing Address - Fax:
Practice Address - Street 1:2100 LOUISIANA BLVD NE STE 410
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5412
Practice Address - Country:US
Practice Address - Phone:505-724-4300
Practice Address - Fax:505-724-4300
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMPA2022-0056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant