Provider Demographics
NPI:1154005908
Name:KENNEDY, JUSTIN J (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:J
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15232-1300
Mailing Address - Country:US
Mailing Address - Phone:412-802-4100
Mailing Address - Fax:
Practice Address - Street 1:5200 CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232-1300
Practice Address - Country:US
Practice Address - Phone:412-802-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant