Healthcare Provider Details

I. General information

NPI: 1881096196
Provider Name (Legal Business Name): KENNETH P WALWORTH III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 N SHIAWASSEE ST STE 201
OWOSSO MI
48867-1632
US

IV. Provider business mailing address

1210 W SAGINAW ST
LANSING MI
48915-1927
US

V. Phone/Fax

Practice location:
  • Phone: 989-725-8124
  • Fax: 989-723-1205
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007136
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: