Healthcare Provider Details

I. General information

NPI: 1245391473
Provider Name (Legal Business Name): MICHAEL ARTHUR KENNEDY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E HWY 120 STE. 104
POTTSBORO TX
75076-3008
US

IV. Provider business mailing address

1038 ADDISON AVE
POTTSBORO TX
75076-7077
US

V. Phone/Fax

Practice location:
  • Phone: 903-786-3911
  • Fax:
Mailing address:
  • Phone: 903-786-8916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA04828
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: