Provider Demographics
NPI:1912952193
Name:GILLESPIE, KENNETH S (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:GILLESPIE
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:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-0096
Mailing Address - Country:US
Mailing Address - Phone:304-763-5167
Mailing Address - Fax:304-763-4062
Practice Address - Street 1:75 AVENUE B
Practice Address - Street 2:
Practice Address - City:RICHWOOD
Practice Address - State:WV
Practice Address - Zip Code:26261-1236
Practice Address - Country:US
Practice Address - Phone:304-846-2573
Practice Address - Fax:304-846-4657
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV979363A00000X
WI2474-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant