Provider Demographics
NPI:1295933125
Name:BOC, KENNETH PACANA (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:PACANA
Last Name:BOC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 FARAON ST.
Mailing Address - Street 2:
Mailing Address - City:ST. JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3488
Mailing Address - Country:US
Mailing Address - Phone:816-271-6406
Mailing Address - Fax:816-271-7986
Practice Address - Street 1:5325 FARAON ST.
Practice Address - Street 2:
Practice Address - City:ST. JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3488
Practice Address - Country:US
Practice Address - Phone:816-271-6406
Practice Address - Fax:816-271-7986
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9406850207R00000X
MO2015032515207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1295933125Medicaid
MO1295933125Medicaid
KS200654820CMedicaid
MOP01573175OtherRR MEDICARE
IA1295933125Medicaid