=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063847994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH J HUEFTLE MSPAS, PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2013
-----------------------------------------------------
Last Update Date | 11/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2301 S BROAD ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19148-3542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-680-8160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1333 FAWN DR
-----------------------------------------------------
City | WILLIAMSTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08094-3488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-680-8160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | OA003525
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | MA057501
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------