MEDICARE: KENNETH WASHINGTON 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
1	363AM0700X	Medical Physician Assistant	MW1058912	OK

General Provider Information

NPI Number	:	1548471857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH WASHINGTON PA-C

Provider Business Mailing Address
First Line	:	1721 SW 33RD ST
Second Line	:
City	:	MOORE
State	:	OK
Zip	:	73160-2926
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2952 SW 59TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73119-6402
Country	:	US
Telephone Number	:	405-495-5154
Fax Number	:	405-666-7144

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	01/06/2009

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Directions to “ KENNETH WASHINGTON PA-C” Practice Location

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