Provider Demographics
NPI:1457486755
Name:DANOS, KENNON
Entity Type:Individual
Prefix:MR
First Name:KENNON
Middle Name:
Last Name:DANOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 3488
Mailing Address - Street 2:DEPT 05-113
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:678-553-8150
Mailing Address - Fax:678-553-8152
Practice Address - Street 1:3301 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4318
Practice Address - Country:US
Practice Address - Phone:228-818-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR726397367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
430071927OtherRAILROAD MEDICARE
640942692OtherBLUE CROSS OF MS
MSKD00016173Medicaid
640942692OtherBLUE CROSS OF MS