Basic Information
| Provider Information | |||||||||
| NPI: | 1669851606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | ADAM | ||||||||
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| Credential: | MPAS, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5579 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977085579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415487761 | ||||||||
| FaxNumber: | 5415983485 | ||||||||
| Practice Location | |||||||||
| Address1: | 1245 NW 4TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415487761 | ||||||||
| FaxNumber: | 5415983485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2015 | ||||||||
| LastUpdateDate: | 04/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363AS0400X | PA180597 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.