Basic Information
| Provider Information | |||||||||
| NPI: | 1942358221 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THIRLBENNY | ||||||||
| FirstName: | KENDEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 8774693649 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 E ARTESIA BLVD | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908051476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624233383 | ||||||||
| FaxNumber: | 8774693649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA 16098 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | EFF: 1/18/2013 | 05 | CA | MEDICAID | PA16098 | 05 | CA | MEDICAID | P01272662/DU4032 | 01 | CA | RAILROAD MEDICARE | OTHER | P01273082 | 01 | CA | RAILROAD MEDICARE-DU4032-WILMINGTON | OTHER |