Provider Demographics
NPI:1518462290
Name:PRENTICE, KENAN STEWART (PA)
Entity Type:Individual
Prefix:
First Name:KENAN
Middle Name:STEWART
Last Name:PRENTICE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 S GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2205
Mailing Address - Country:US
Mailing Address - Phone:901-759-5443
Mailing Address - Fax:901-435-5665
Practice Address - Street 1:1400 S GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2205
Practice Address - Country:US
Practice Address - Phone:901-759-5443
Practice Address - Fax:901-435-5665
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant