Provider Demographics
NPI:1710941059
Name:RICE, KENNETH COLEMAN (PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:COLEMAN
Last Name:RICE
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 1:6300 N WICKHAM RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2023
Mailing Address - Country:US
Mailing Address - Phone:321-242-7425
Mailing Address - Fax:
Practice Address - Street 1:6300 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2028
Practice Address - Country:US
Practice Address - Phone:321-242-7425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09853363A00000X
FLPA3323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS73613Medicare UPIN