Provider Demographics
NPI:1356058606
Name:AGUILAR, KENNY
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:AGUILAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 SPRUCE ST APT A204
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4758
Mailing Address - Country:US
Mailing Address - Phone:909-549-9639
Mailing Address - Fax:
Practice Address - Street 1:4301 SPRUCE ST APT A204
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4758
Practice Address - Country:US
Practice Address - Phone:909-549-9639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY841870390200000X
PARN720771390200000X
NY841870-01367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program