Provider Demographics
NPI:1760293641
Name:KENWABIKISE, LARYN C (PA-C)
Entity type:Individual
Prefix:
First Name:LARYN
Middle Name:C
Last Name:KENWABIKISE
Suffix:
Gender:F
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 1:2098 ESSEX VIEW DR APT 205
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-8829
Mailing Address - Country:US
Mailing Address - Phone:231-878-7902
Mailing Address - Fax:
Practice Address - Street 1:1221 SIXTH ST STE 300
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2360
Practice Address - Country:US
Practice Address - Phone:231-392-0640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-18
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601012983363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical