Healthcare Provider Details

I. General information

NPI: 1922096379
Provider Name (Legal Business Name): KENNETH ALLEN MITCHELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 LAKE RD SUITE 200
WOODBURY MN
55125-1712
US

IV. Provider business mailing address

1300 CENTERVIEW DR
LITTLE ROCK AR
72211-4349
US

V. Phone/Fax

Practice location:
  • Phone: 651-999-6800
  • Fax: 651-999-6830
Mailing address:
  • Phone: 501-219-8900
  • Fax: 501-410-1148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA970
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10025
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: