Provider Demographics
NPI:1760558795
Name:SPILIOS, KENNETH WAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:SPILIOS
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 1:8676 E MOCCASIN SLOUGH RD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34450-6127
Mailing Address - Country:US
Mailing Address - Phone:352-637-0320
Mailing Address - Fax:
Practice Address - Street 1:6152 W CORPORATE OAKS DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-8722
Practice Address - Country:US
Practice Address - Phone:352-794-5086
Practice Address - Fax:352-794-5089
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1642363AM0700X
MI5601004450363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP05264Medicare UPIN
FLE4031ZMedicare ID - Type Unspecified