Provider Demographics
NPI:1629017900
Name:UNDERWOOD, KENNETH LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEE
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 20828
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86439-0828
Mailing Address - Country:US
Mailing Address - Phone:928-763-2001
Mailing Address - Fax:928-763-2038
Practice Address - Street 1:3015 HIGHWAY 95
Practice Address - Street 2:SUITE 105
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-4334
Practice Address - Country:US
Practice Address - Phone:928-763-2001
Practice Address - Fax:928-763-2038
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ1934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant