Provider Demographics
NPI:1891856159
Name:KINNAN, KENNETH DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DAVID
Last Name:KINNAN
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 1:120 NE SAINT LUKES BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-6011
Mailing Address - Country:US
Mailing Address - Phone:816-246-4302
Mailing Address - Fax:816-246-9493
Practice Address - Street 1:120 NE SAINT LUKES BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086
Practice Address - Country:US
Practice Address - Phone:816-246-4302
Practice Address - Fax:816-246-9493
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00968363A00000X, 363AS0400X
MO2008021981363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS248B00004Medicare PIN
Q21030Medicare UPIN
KSP00778559Medicare PIN
MO248A00004Medicare PIN