Provider Demographics
NPI:1548236953
Name:STRADLING, KENNARD (MD)
Entity Type:Individual
Prefix:
First Name:KENNARD
Middle Name:
Last Name:STRADLING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 N BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2357
Mailing Address - Country:US
Mailing Address - Phone:505-566-1915
Mailing Address - Fax:505-566-1918
Practice Address - Street 1:3451 N BUTLER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2357
Practice Address - Country:US
Practice Address - Phone:505-566-1915
Practice Address - Fax:505-566-1918
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91319207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00016645Medicaid
NM00016645Medicaid
NMS000501017Medicare ID - Type Unspecified