Provider Demographics
NPI:1922051614
Name:KENICK, MATTHEW M (PAC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:M
Last Name:KENICK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NW 49TH STREET
Mailing Address - Street 2:SUITE 125
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3763
Mailing Address - Country:US
Mailing Address - Phone:954-355-4665
Mailing Address - Fax:
Practice Address - Street 1:1625 SE 3RD AVENUE
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316
Practice Address - Country:US
Practice Address - Phone:954-355-4665
Practice Address - Fax:954-355-4881
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290516700Medicaid
R54742Medicare UPIN
FLE1455ZMedicare ID - Type Unspecified