Provider Demographics
NPI:1497037550
Name:BYRD, KENNETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BYRD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-851-6033
Mailing Address - Fax:615-296-9937
Practice Address - Street 1:312 ARMSTRONG ST
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-3606
Practice Address - Country:US
Practice Address - Phone:855-933-6286
Practice Address - Fax:865-217-1094
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6094174OtherBCBS OF TN
TN1525628Medicaid
TN103I972926Medicare PIN
TN103I979809Medicare PIN