Provider Demographics
NPI:1588631337
Name:LANDIN, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JOHN
Last Name:LANDIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:JOHN NEIL
Other - Last Name:MATWICHUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 890291
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 SOUTHSIDE AVE
Practice Address - Street 2:SUITE350
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4160
Practice Address - Country:US
Practice Address - Phone:828-277-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059269L207Q00000X
NC2015-02371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1588631337Medicaid
PA1590117Medicaid
NCNCR678AMedicare PIN
F69841Medicare UPIN