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General NPI Number Information
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NPI Number | 1922096379
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Entity Type | Individual
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Provider Name | KENNETH ALLEN MITCHELL PA-C
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Gender | Male
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Dates
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Enumeration Date | 10/10/2005
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Last Update Date | 04/05/2021
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Provider Practice Location Address
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Address Line | 6025 LAKE RD SUITE 200
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City | WOODBURY
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State | MN
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Zip | 55125-1712
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Country | US
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Telephone | 651-999-6800
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Fax | 651-999-6830
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Provider Business Mailing Address
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Address Line | 1300 CENTERVIEW DR
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City | LITTLE ROCK
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State | AR
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Zip | 72211-4349
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Country | US
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Telephone | 501-219-8900
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Fax | 501-410-1148
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA970
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 10025
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License Number State | MN
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