Provider Demographics
NPI:1982166377
Name:YAW, KENNETH EDWARD (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:EDWARD
Last Name:YAW
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 1:8064 STEAMBOAT CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERSET
Mailing Address - State:SD
Mailing Address - Zip Code:57769-6213
Mailing Address - Country:US
Mailing Address - Phone:209-601-0780
Mailing Address - Fax:
Practice Address - Street 1:8064 STEAMBOAT CT
Practice Address - Street 2:
Practice Address - City:SUMMERSET
Practice Address - State:SD
Practice Address - Zip Code:57769-6213
Practice Address - Country:US
Practice Address - Phone:209-601-0780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7377363A00000X
SD1363363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant