Provider Demographics
NPI:1528287422
Name:DEGNER, KENNETH (PA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:DEGNER
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 6037
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-6037
Mailing Address - Country:US
Mailing Address - Phone:847-526-2151
Mailing Address - Fax:847-526-2017
Practice Address - Street 1:431 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-2452
Practice Address - Country:US
Practice Address - Phone:847-526-2151
Practice Address - Fax:847-526-2017
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000019363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP92582Medicare UPIN
L99549Medicare ID - Type Unspecified