Provider Demographics
NPI:1609100692
Name:BURGESS, KENDRA M (PA-C)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:M
Last Name:BURGESS
Suffix:
Gender:F
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 1:5000 KY ROUTE 321
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-9113
Mailing Address - Country:US
Mailing Address - Phone:606-886-8511
Mailing Address - Fax:606-886-1316
Practice Address - Street 1:5000 KY ROUTE 321
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9113
Practice Address - Country:US
Practice Address - Phone:606-886-8511
Practice Address - Fax:606-886-1316
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
KYPA1210363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100242920Medicaid