Provider Demographics
NPI:1942280052
Name:KENNEDY, HOWARD MICHAEL JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:HOWARD
Middle Name:MICHAEL
Last Name:KENNEDY
Suffix:JR
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 1:4957 SWINYAR DR STE 109
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-2205
Mailing Address - Country:US
Mailing Address - Phone:423-432-3130
Mailing Address - Fax:423-396-9508
Practice Address - Street 1:4957 SWINYAR DR STE 109
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-2205
Practice Address - Country:US
Practice Address - Phone:423-432-3130
Practice Address - Fax:423-396-9508
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN408363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36660801Medicaid
TN36660801Medicaid
S00652Medicare UPIN