Provider Demographics
NPI:1184977514
Name:BOTELHO, KENNETH CUSHING (PA-C)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:CUSHING
Last Name:BOTELHO
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 1:450 VETERANS MEMORIAL PKWY BLDG 9
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-5300
Mailing Address - Country:US
Mailing Address - Phone:401-435-5533
Mailing Address - Fax:401-435-3586
Practice Address - Street 1:450 VETERANS MEMORIAL PKWY BLDG 9
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5300
Practice Address - Country:US
Practice Address - Phone:401-435-5533
Practice Address - Fax:401-435-3586
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15285363A00000X
RIPA00716363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant