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Ethan Raymond Kenney

Physician Assistant

Physician Assistants & Advanced Practice Nursing Providers

15830 Ballantyne Medical Pl Ste 275, Charlotte, NC 28277-4791

PECOS Enrollment

This provider is enrolled in PECOS as ETHAN KENNEY.

Based on the most recent information from CMS, provider Ethan Raymond Kenney is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.

Part B
Medicare Part B
Enrolled
HHA
Home Health Agency
Enrolled
DME
Durable Medical Equipment
Enrolled
PMD
Power Mobility Device
Enrolled

CMS last updated its PECOS records 2 days ago.

Profile Details

Provider ID
1346870821
Provider Type
Individual
Full Name
Kenney, Ethan Raymond
Title
Mr.
Credential
PHYSICIAN ASSISTANT

Gender
Male
Sole Proprietor
No
Enumeration Date
1/23/2020
Last Updated
2/12/2024

Contact Information

Practice Location

15830 Ballantyne Medical Pl Ste 275, Charlotte, NC 28277-4791

(980) 302-8659

(980) 302-8674

Mailing Location

PO Box 60447, Charlotte, NC 28260-0447

(980) 302-8659

(980) 302-8674

Provider Taxonomies

Code	Description	License
Code 363A00000X Primary	Description Physician Assistant Physician Assistants & Advanced Practice Nursing Providers	License 0010-09714 North Carolina

Ethan Raymond Kenney

PECOS Enrollment

Profile Details

Contact Information

Practice Location

Mailing Location

Provider Taxonomies

Code

Description

License

Code

Description

License

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