Provider Demographics
NPI:1861430209
Name:PARDOE, KENNETH L (PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:PARDOE
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:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:7116 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-2904
Practice Address - Country:US
Practice Address - Phone:443-577-0277
Practice Address - Fax:443-577-0288
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000884363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK727369UMedicare PIN
MD239824YVZ - 945LMedicare PIN
MD239825ZDDB - 149619Medicare PIN
MDS43385Medicare UPIN