Provider Demographics
NPI:1295748408
Name:HENRY, KENNETH ROY (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROY
Last Name:HENRY
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 1:115 NEW HALLTOWN RD
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37074-1929
Mailing Address - Country:US
Mailing Address - Phone:615-374-0006
Mailing Address - Fax:
Practice Address - Street 1:3939 CENTRAL PIKE
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-3499
Practice Address - Country:US
Practice Address - Phone:615-883-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN749363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP48501Medicare UPIN