Provider Demographics
NPI:1194083295
Name:BAIRD, KENNETH REESE (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:REESE
Last Name:BAIRD
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 1:1665 W LAKOTA DR
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-6649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1665 W LAKOTA DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-6649
Practice Address - Country:US
Practice Address - Phone:888-434-8880
Practice Address - Fax:885-434-8880
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0004087363A00000X
NVPA2699363A00000X
UT11579540-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1194083295Medicaid