Provider Demographics
NPI:1821055047
Name:BANNON, KENNETH JOHN (BSPA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JOHN
Last Name:BANNON
Suffix:
Gender:M
Credentials:BSPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 SALEM AVENUE
Practice Address - Street 2:SUITE 302
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-2574
Practice Address - Country:US
Practice Address - Phone:570-282-2031
Practice Address - Fax:570-282-2534
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001023L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA034606S63Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PAR06447Medicare UPIN