Provider Demographics
NPI:1659445971
Name:PATTERSON, KENNETH RUSSELL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RUSSELL
Last Name:PATTERSON
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 1:4700 LV BLVD. N.
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6601
Mailing Address - Country:US
Mailing Address - Phone:702-653-2344
Mailing Address - Fax:
Practice Address - Street 1:4700 LV BLVD. N.
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6601
Practice Address - Country:US
Practice Address - Phone:702-653-2344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20090363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant