Provider Demographics
NPI:1891984548
Name:EATON, KENNWORTH II (PA)
Entity type:Individual
Prefix:MR
First Name:KENNWORTH
Middle Name:
Last Name:EATON
Suffix:II
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 1:240 W MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-3510
Mailing Address - Country:US
Mailing Address - Phone:631-728-4500
Mailing Address - Fax:631-728-4564
Practice Address - Street 1:240 W MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-3510
Practice Address - Country:US
Practice Address - Phone:631-728-4500
Practice Address - Fax:631-728-4564
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant