Provider Demographics
NPI:1902271547
Name:KENNAH PA-C, BENNJAMIN L (PA-C)
Entity Type:Individual
Prefix:
First Name:BENNJAMIN
Middle Name:L
Last Name:KENNAH PA-C
Suffix:
Gender:M
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 1:2741 DEBARR RD
Mailing Address - Street 2:STE C214
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2978
Mailing Address - Country:US
Mailing Address - Phone:907-644-6055
Mailing Address - Fax:907-644-4885
Practice Address - Street 1:2741 DEBARR RD STE C214
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2978
Practice Address - Country:US
Practice Address - Phone:907-644-6055
Practice Address - Fax:907-644-4885
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK103875363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical