Provider Demographics
NPI:1679130322
Name:VALES KENNEDY, GUILLERMO (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GUILLERMO
Middle Name:
Last Name:VALES KENNEDY
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 1:1401 S LAVENTURE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-6033
Mailing Address - Country:US
Mailing Address - Phone:360-424-7041
Mailing Address - Fax:
Practice Address - Street 1:1500 CONTINENTAL PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-424-7041
Practice Address - Fax:360-424-2418
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA60912831363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2137460Medicaid