Provider Demographics
NPI:1528415767
Name:KENNEDY, JUSTIN MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5845 PINEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-3859
Mailing Address - Country:US
Mailing Address - Phone:817-845-5114
Mailing Address - Fax:
Practice Address - Street 1:2020 W ST HWY 114
Practice Address - Street 2:SUITE 120
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8649
Practice Address - Country:US
Practice Address - Phone:817-912-8300
Practice Address - Fax:817-912-8310
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical