Provider Demographics
NPI:1417939943
Name:OSBORN, KENNETH M (RPAC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:M
Last Name:OSBORN
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-1442
Mailing Address - Country:US
Mailing Address - Phone:716-592-3614
Mailing Address - Fax:716-592-2929
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-1442
Practice Address - Country:US
Practice Address - Phone:716-592-3614
Practice Address - Fax:716-592-2929
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003354363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01274304Medicaid
NYS67053Medicare UPIN
NY01274304Medicaid