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NPI Code Detail

MEDICARE: MR. STEPHEN G KENNEBECK PA-C

MEDICARE: MR. STEPHEN G KENNEBECK PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant1043WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1538169214
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. STEPHEN G KENNEBECK PA-C
Provider Business Mailing Address
First Line : 855 N WESTHAVEN DR
Second Line :
City : OSHKOSH
State : WI
Zip : 54904-7668
Country : US
Telephone Number : 920-303-8786
Fax Number :
Provider Business Practice Location Address
First Line : 855 N WESTHAVEN DR
Second Line :
City : OSHKOSH
State : WI
Zip : 54904-7668
Country : US
Telephone Number : 920-303-8700
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/26/2005
Last Update Date : 11/26/2021

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Directions to “ MR. STEPHEN G KENNEBECK PA-C” Practice Location

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