Provider Demographics
NPI:1578502696
Name:SANDERS, KENNETH MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:SANDERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 COVE POINTE RD
Mailing Address - Street 2:
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-5945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:923 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2768
Practice Address - Country:US
Practice Address - Phone:423-907-1200
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000443363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4108109OtherBCBS
TNP00310586OtherMEDICARE RAILROAD
TNP00310586OtherMEDICARE RAILROAD
TNP00814Medicare UPIN