Provider Demographics
NPI:1700969649
Name:SMITH, KENNETH WARREN SR (APA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WARREN
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:APA-C
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Other - First Name:
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Mailing Address - Street 1:8901 ROCKVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-0001
Mailing Address - Country:US
Mailing Address - Phone:301-400-2846
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:TRIPLER ARMY MEDICAL CENTER ATTN: MCHK-QS
Practice Address - City:TAMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-2460
Practice Address - Fax:808-433-1558
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2015-10-22
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN