Provider Demographics
NPI:1720184518
Name:SHERRY, KENNETH D (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:SHERRY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CEDAR CREST CT
Mailing Address - Street 2:
Mailing Address - City:ORWIGSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17961-2344
Mailing Address - Country:US
Mailing Address - Phone:570-366-1932
Mailing Address - Fax:
Practice Address - Street 1:700 E NORWEGIAN ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2710
Practice Address - Country:US
Practice Address - Phone:570-621-4143
Practice Address - Fax:570-621-4769
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000093L363A00000X
PAMA000951L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA096750MK6Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER