Provider Demographics
NPI:1669807210
Name:PHELPS, KENNETH RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:RICHARD
Last Name:PHELPS
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:PO BOX 200096
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-9002
Mailing Address - Country:US
Mailing Address - Phone:678-905-7053
Mailing Address - Fax:678-905-7053
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:BLDG. 300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4252
Practice Address - Country:US
Practice Address - Phone:904-399-5550
Practice Address - Fax:904-346-4334
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant