Provider Demographics
NPI:1386937993
Name:CHILDERS, KENNETH DEWEY JR (CRNA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DEWEY
Last Name:CHILDERS
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 ORTEGA ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-4247
Mailing Address - Country:US
Mailing Address - Phone:415-290-1884
Mailing Address - Fax:
Practice Address - Street 1:2550 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4327
Practice Address - Country:US
Practice Address - Phone:530-529-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA585519367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered