Provider Demographics
NPI:1922096379
Name:MITCHELL, KENNETH ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALLEN
Last Name:MITCHELL
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 1:1300 CENTERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4349
Mailing Address - Country:US
Mailing Address - Phone:501-219-8900
Mailing Address - Fax:501-410-1148
Practice Address - Street 1:6025 LAKE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1712
Practice Address - Country:US
Practice Address - Phone:651-999-6800
Practice Address - Fax:651-999-6830
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA970363A00000X
MN10025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN534141800Medicaid
MN534141800Medicaid
MN970002287Medicare ID - Type Unspecified