Provider Demographics
NPI:1568637395
Name:PETERSEN, KENNETH WENDELL (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WENDELL
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E ROCK HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-4411
Mailing Address - Country:US
Mailing Address - Phone:816-380-3474
Mailing Address - Fax:
Practice Address - Street 1:2820 E ROCK HAVEN RD
Practice Address - Street 2:SUITE # 120
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-4411
Practice Address - Country:US
Practice Address - Phone:816-380-7662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-33327207X00000X
MO2013002819207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200570110AMedicaid
KS200570110AMedicaid