Provider Demographics
NPI:1457442964
Name:WASSON, KENNETH RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RICHARD
Last Name:WASSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 OAK ST APT 19
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-2674
Mailing Address - Country:US
Mailing Address - Phone:850-561-1565
Mailing Address - Fax:850-878-8900
Practice Address - Street 1:1607 SAINT JAMES CT
Practice Address - Street 2:TOPC
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5352
Practice Address - Country:US
Practice Address - Phone:850-878-0191
Practice Address - Fax:850-878-8900
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME18647207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine