Provider Demographics
NPI:1295731081
Name:EDMISSON, KENNETH WAYNE JR (ND EDD RNC FNP CRNA)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:EDMISSON
Suffix:JR
Gender:M
Credentials:ND EDD RNC FNP CRNA
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:225 MEDICAL CENTER DR
Mailing Address - Street 2:#405
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7914
Mailing Address - Country:US
Mailing Address - Phone:270-441-4750
Mailing Address - Fax:
Practice Address - Street 1:225 MEDICAL CENTER DR
Practice Address - Street 2:#405
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7914
Practice Address - Country:US
Practice Address - Phone:270-441-4750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-26
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000006429363LF0000X
VA0024162111363LF0000X
KY3007055367500000X
TN6429367500000X
TX1659367500000X
OH12386-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK031290Medicare PIN