Provider Demographics
NPI:1518162221
Name:ANDERSON, KENNETH WADE (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WADE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 S VOZACK LN STE C
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748-4539
Mailing Address - Country:US
Mailing Address - Phone:520-278-5202
Mailing Address - Fax:800-392-0662
Practice Address - Street 1:250 S VOZACK LN STE C
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85748-4539
Practice Address - Country:US
Practice Address - Phone:520-278-5202
Practice Address - Fax:800-392-0662
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-009417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist