Healthcare Provider Details

I. General information

NPI: 1386606473
Provider Name (Legal Business Name): KENNETH MARTIN WINTERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MUIR RD VA OUTPATIENT CLINIC
MARTINEZ CA
94553
US

IV. Provider business mailing address

150 MUIR RD VA OUTPATIENT CLINIC
MARTINEZ CA
94553
US

V. Phone/Fax

Practice location:
  • Phone: 925-372-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 16229
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: