Provider Demographics
NPI:1124178967
Name:KENNESON, STEPHEN T (PA)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:T
Last Name:KENNESON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 GLEASONDALE RD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:MA
Mailing Address - Zip Code:01775-1334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MASSACHUSETTS GENERAL HOSPITAL CARDIAC SURGERY
Practice Address - Street 2:55 FRUIT STREET
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-1861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA527363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical