Provider Demographics
NPI:1972599678
Name:KENNEDY, MICHAEL D (PA C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:KENNEDY
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 1:86 THOMAS JOHNSON CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4348
Mailing Address - Country:US
Mailing Address - Phone:301-694-8311
Mailing Address - Fax:
Practice Address - Street 1:86 THOMAS JOHNSON CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4348
Practice Address - Country:US
Practice Address - Phone:301-694-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002738363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP97859Medicare UPIN
MDS999G945Medicare PIN