Provider Demographics
NPI:1427240019
Name:WILLOUGHBY, KENNETH JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:WILLOUGHBY
Suffix:JR
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32051 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-1906
Mailing Address - Country:US
Mailing Address - Phone:440-930-2802
Mailing Address - Fax:
Practice Address - Street 1:32051 GROVE ST
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-1906
Practice Address - Country:US
Practice Address - Phone:440-930-2802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
SC4370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical