Provider Demographics
NPI:1659350544
Name:SWANSON, KENNETH (NP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SWANSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 VILLAGE HWY
Mailing Address - Street 2:
Mailing Address - City:RUSTBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24588-4591
Mailing Address - Country:US
Mailing Address - Phone:434-332-7367
Mailing Address - Fax:434-332-1757
Practice Address - Street 1:925 VILLAGE HWY
Practice Address - Street 2:
Practice Address - City:RUSTBURG
Practice Address - State:VA
Practice Address - Zip Code:24588-4591
Practice Address - Country:US
Practice Address - Phone:434-332-7367
Practice Address - Fax:434-332-1757
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024000007363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
541663754OtherCVFP TIN
P04208Medicare UPIN
VA00V946J04Medicare PIN
VV1997A CVFPMedicare PIN