Provider Demographics
NPI:1144541947
Name:VINH, KENNY B (PA)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:B
Last Name:VINH
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 1:515 S BEACH BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-1812
Mailing Address - Country:US
Mailing Address - Phone:714-995-7503
Mailing Address - Fax:714-731-8310
Practice Address - Street 1:515 S BEACH BLVD STE F
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-1812
Practice Address - Country:US
Practice Address - Phone:714-995-7503
Practice Address - Fax:714-731-8310
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20539363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical