Provider Demographics
NPI:1205487170
Name:MORRISON, KENNETH D (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:D
Last Name:MORRISON
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 1:223 EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4202
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:225 EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4202
Practice Address - Country:US
Practice Address - Phone:502-855-7200
Practice Address - Fax:502-855-7201
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PDZ000000419794OtherAETNA BETTER HEALTH OF KY PROVIDER ID NUMBER
000001400660OtherANTHEM PROVIDER ID
IN300040508Medicaid
KY7100631240Medicaid
14556232OtherCAQH PROVIDER ID
CS2027500153OtherCARESOURCE PROVIDER ID NUMBER