Provider Demographics
NPI:1699205328
Name:KENNEDY, NATHANIEL GEORGE (PA)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:GEORGE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5316 GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-8843
Mailing Address - Country:US
Mailing Address - Phone:612-787-8818
Mailing Address - Fax:
Practice Address - Street 1:3101 BARDSTOWN ROAD
Practice Address - Street 2:SULLIVAN UNIVERSITY PHYSICIAN ASSISTANT PROGRAM
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205
Practice Address - Country:US
Practice Address - Phone:502-413-8659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant