Provider Demographics
NPI:1851801823
Name:ADAMS, KENNETH B (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
Last Name:ADAMS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S BALLAS RD STE 3005B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5314
Mailing Address - Country:US
Mailing Address - Phone:314-567-5850
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 3005B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8266
Practice Address - Country:US
Practice Address - Phone:314-567-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020040966363A00000X
IN10002325A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300011444Medicaid