Provider Demographics
NPI:1285766600
Name:ROMANS, KENNETH S (PA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:S
Last Name:ROMANS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-0580
Mailing Address - Country:US
Mailing Address - Phone:209-419-0956
Mailing Address - Fax:209-893-0420
Practice Address - Street 1:588 ST CHARLES STREET
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-418-8121
Practice Address - Fax:209-893-0420
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA105742Medicare PIN