Provider Demographics
NPI:1881189116
Name:DABOLT, KENNETH DEAN RICHARD (RPA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DEAN RICHARD
Last Name:DABOLT
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-1443
Mailing Address - Country:US
Mailing Address - Phone:716-592-8140
Mailing Address - Fax:
Practice Address - Street 1:224 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-1443
Practice Address - Country:US
Practice Address - Phone:716-592-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022107-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant