Provider Demographics
NPI:1699746487
Name:EBERSOLE, KENNETH ALLAN (APRN,FNP)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ALLAN
Last Name:EBERSOLE
Suffix:
Gender:M
Credentials:APRN,FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:501 DOCTOR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8258
Mailing Address - Fax:337-312-6708
Practice Address - Street 1:277 N HIGHWAY 171
Practice Address - Street 2:SUITE 10
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5374
Practice Address - Country:US
Practice Address - Phone:337-217-7762
Practice Address - Fax:337-855-5310
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAAP03160363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1558761Medicaid
LAP01076979Medicare PIN
LAS54701Medicare UPIN
LA1558761Medicaid
LA5X5147460Medicare PIN