Provider Demographics
NPI:1366531337
Name:ADAMS, KENNETH A (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:A
Last Name:ADAMS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-7670
Mailing Address - Country:US
Mailing Address - Phone:918-682-4085
Mailing Address - Fax:
Practice Address - Street 1:3001 W BLUE STARR DR
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-2544
Practice Address - Country:US
Practice Address - Phone:918-342-5432
Practice Address - Fax:918-342-0835
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA376363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical