Provider Demographics
NPI:1134397870
Name:CHANG, KENNY (PAC)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:CHANG
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 1:12021 WILSHIRE BLVD STE 745
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1206
Mailing Address - Country:US
Mailing Address - Phone:310-348-1900
Mailing Address - Fax:
Practice Address - Street 1:12021 WILSHIRE BLVD STE 745
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1206
Practice Address - Country:US
Practice Address - Phone:310-348-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16068173000000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No173000000XOther Service ProvidersLegal Medicine