Basic Information
| Provider Information | |||||||||
| NPI: | 1730419870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMOTT | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEMOTT | ||||||||
| OtherFirstName: | KENNETH | ||||||||
| OtherMiddleName: | EDWARD | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 39 PEARL ST W | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138381330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075612021 | ||||||||
| FaxNumber: | 6075632663 | ||||||||
| Practice Location | |||||||||
| Address1: | 39 PEARL ST W | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138381330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075612021 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2010 | ||||||||
| LastUpdateDate: | 02/24/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 336161 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.