Provider Demographics
NPI:1245313816
Name:ST. OURS, KENNETH A (PA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:A
Last Name:ST. OURS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 COLONIAL CT
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4317
Mailing Address - Country:US
Mailing Address - Phone:410-832-5469
Mailing Address - Fax:
Practice Address - Street 1:8118 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3595
Practice Address - Country:US
Practice Address - Phone:301-498-5990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001047363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP15587Medicare UPIN
DC005896D14Medicare PIN