Provider Demographics
NPI:1295805661
Name:WENSLOW, KENNETH DALE (PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DALE
Last Name:WENSLOW
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 1:12389 CRABAPPLE RD
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-6328
Mailing Address - Country:US
Mailing Address - Phone:470-299-1998
Mailing Address - Fax:470-299-1898
Practice Address - Street 1:12389 CRABAPPLE RD
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-6328
Practice Address - Country:US
Practice Address - Phone:470-299-1998
Practice Address - Fax:470-299-1898
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA002823OtherLICENSE NUMBER
GA002823OtherLICENSE NUMBER
GA002823OtherLICENSE NUMBER