Healthcare Provider Details

I. General information

NPI: 1346496866
Provider Name (Legal Business Name): KENNETH G WAUGH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 LINBLAD AVE.
GIRDWOOD AK
99587
US

IV. Provider business mailing address

PO BOX 651
GIRDWOOD AK
99587-0651
US

V. Phone/Fax

Practice location:
  • Phone: 907-783-2311
  • Fax:
Mailing address:
  • Phone: 907-783-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number507
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: