Provider Demographics
NPI:1316912470
Name:STEGALL, KENNETH W (PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:STEGALL
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:105 ZEID BLVD BLDG 2
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-6070
Practice Address - Country:US
Practice Address - Phone:903-315-5612
Practice Address - Fax:903-657-0139
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-017OtherTRICARE
TX75-2616977-129OtherTRICARE
TX8N4367OtherBCBS FOR TC
TX8N4367OtherBCBS FOR TC
TX8D1177Medicare ID - Type Unspecified
TXP00192644Medicare PIN
TX8D1177Medicare Oscar/Certification