Provider Demographics
NPI:1477884138
Name:TAM, KENNETH (NP-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:TAM
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9048 HERRING COVE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-6269
Mailing Address - Country:US
Mailing Address - Phone:512-743-1829
Mailing Address - Fax:512-590-7104
Practice Address - Street 1:4141 SWENSON ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6718
Practice Address - Country:US
Practice Address - Phone:702-733-0320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP118688363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily