Provider Demographics
NPI:1134716012
Name:GUY, KENNETH L JR
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:GUY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24613 FAIRLAWN DR
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-2768
Mailing Address - Country:US
Mailing Address - Phone:734-626-9949
Mailing Address - Fax:
Practice Address - Street 1:6225 NORTH STATE HWY 161 STE 200
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2241
Practice Address - Country:US
Practice Address - Phone:214-687-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704299199367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered