Provider Demographics
NPI:1699828152
Name:ROLAND, KENNETH B JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:B
Last Name:ROLAND
Suffix:JR
Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:300 W. HOSPITAL ROAD
Mailing Address - Street 2:EISENHOWER ARMY MEDICAL CENTER
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-2720
Mailing Address - Country:US
Mailing Address - Phone:706-787-4697
Mailing Address - Fax:706-787-6735
Practice Address - Street 1:300 W. HOSPITAL ROAD
Practice Address - Street 2:EISENHOWER ARMY MEDICAL CENTER
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-2720
Practice Address - Country:US
Practice Address - Phone:706-787-4697
Practice Address - Fax:706-787-6735
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC688363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN