Provider Demographics
NPI:1417973231
Name:WARNER, KENNETH H (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:WARNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3537 W FRONT ST STE E
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7943
Mailing Address - Country:US
Mailing Address - Phone:231-935-8930
Mailing Address - Fax:231-935-8811
Practice Address - Street 1:3537 W FRONT ST STE E
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7943
Practice Address - Country:US
Practice Address - Phone:231-935-8930
Practice Address - Fax:231-935-8811
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004373363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1152915100OtherBCBS
MI1152915100OtherBCBS
MIM02890 P12Medicare PIN