Provider Demographics
NPI:1881096196
Name:WALWORTH, KENNETH P III (PA-C)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
Last Name:WALWORTH
Suffix:III
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 1:1210 W SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48915-1927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:721 N SHIAWASSEE ST STE 201
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1632
Practice Address - Country:US
Practice Address - Phone:989-725-8124
Practice Address - Fax:989-723-1205
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007136363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1881096196Medicaid