Provider Demographics
NPI:1750305066
Name:MILLSAP, KENNETH L (NP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:MILLSAP
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 E BARNETT RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8344
Mailing Address - Country:US
Mailing Address - Phone:541-789-5250
Mailing Address - Fax:
Practice Address - Street 1:520 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4334
Practice Address - Country:US
Practice Address - Phone:541-789-5710
Practice Address - Fax:541-789-5711
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450110NPFNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR292119Medicaid
ORR131456Medicare ID - Type Unspecified
OR292119Medicaid