Provider Demographics
NPI:1023148210
Name:BURNETT, KEDRON FJ (PA-C)
Entity type:Individual
Prefix:
First Name:KEDRON
Middle Name:FJ
Last Name:BURNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:US DEPT OF STATE
Mailing Address - Street 2:M/MED/QI, SA-1
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20522-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 16TH AVE N
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-4058
Practice Address - Country:US
Practice Address - Phone:208-467-4431
Practice Address - Fax:208-467-7684
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID527363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-527OtherIDAHO MEDICAL LICENSE
IDPA-527OtherIDAHO MEDICAL LICENSE