Provider Demographics
NPI:1881693109
Name:SUN, KENNETH P (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
Last Name:SUN
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 1:382 EPPS ST
Mailing Address - Street 2:PO BOX 266
Mailing Address - City:WIND GAP
Mailing Address - State:PA
Mailing Address - Zip Code:18091-9717
Mailing Address - Country:US
Mailing Address - Phone:610-863-8598
Mailing Address - Fax:610-863-0267
Practice Address - Street 1:382 EPPS ST
Practice Address - Street 2:BOX 266
Practice Address - City:WIND GAP
Practice Address - State:PA
Practice Address - Zip Code:18091-9717
Practice Address - Country:US
Practice Address - Phone:610-863-8598
Practice Address - Fax:610-863-0267
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
PAMD056132L207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF90159Medicare UPIN
PA777373Medicare ID - Type Unspecified