Provider Demographics
NPI:1215155056
Name:WENTWORTH, KEVIN J (RPA-C)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:J
Last Name:WENTWORTH
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLARA BARTON STREET
Mailing Address - Street 2:
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-9503
Mailing Address - Country:US
Mailing Address - Phone:585-335-6001
Mailing Address - Fax:
Practice Address - Street 1:111 CLARA BARTON ST
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-9503
Practice Address - Country:US
Practice Address - Phone:585-335-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2269363A00000X
NY002269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY149288OtherPREFERRED CARE
BB4699Medicare PIN
NYR70789Medicare UPIN