Provider Demographics
NPI:1720080393
Name:KENNEDY, TODD EDWARD (PA-C)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:EDWARD
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:704-978-3549
Practice Address - Street 1:142 SHERLOCK DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-1953
Practice Address - Country:US
Practice Address - Phone:704-838-8256
Practice Address - Fax:704-838-8251
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC103906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2761055Medicare PIN
Q22566Medicare UPIN