Provider Demographics
NPI:1942358221
Name:THIRLBENNY, KENDEL (PA-C)
Entity Type:Individual
Prefix:
First Name:KENDEL
Middle Name:
Last Name:THIRLBENNY
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 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4302
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:877-469-3649
Practice Address - Street 1:540 E ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-1476
Practice Address - Country:US
Practice Address - Phone:562-423-3383
Practice Address - Fax:877-469-3649
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 16098363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFF: 1/18/2013Medicaid
CAPA16098Medicaid
CAP01272662/DU4032OtherRAILROAD MEDICARE
CAP01273082OtherRAILROAD MEDICARE-DU4032-WILMINGTON
CA0PA160983Medicare PIN
CAWPA16098CMedicare PIN
CAWPA16098HMedicare PIN
CAGB030ZMedicare PIN
CAWPA16098BMedicare PIN
CAP01273082OtherRAILROAD MEDICARE-DU4032-WILMINGTON
CAEFF: 1/18/2013Medicaid
CAPA16098Medicaid
CAGB232BMedicare PIN
CAWPA16098EMedicare PIN
AK0PA160984Medicare PIN
CA0PA160981Medicare PIN
CAP01272662/DU4032OtherRAILROAD MEDICARE