Provider Demographics
NPI:1356749014
Name:KENNEDY, GABRIEL (PA-C)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:KENNEDY
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 1:650 HUEBNER RD
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-4030
Mailing Address - Country:US
Mailing Address - Phone:785-239-3627
Mailing Address - Fax:
Practice Address - Street 1:650 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-4030
Practice Address - Country:US
Practice Address - Phone:785-239-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA-13679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant