Kenneth Willoughby Jr., PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

4370 Issued in SC

Practice address

32051 Grove St
Avon Lake, OH 44012-1906

Phone

(440) 930-2802

NPI assigned

Aug 16, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in GA, SC2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 2

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Acs Primary Care Physicians - Southeast PC

  • Emergency Medicine Physician
  • Myrtle Beach, SC
  • NPI 1861430555

  GA

  Medicare reassignment
• Cep America LLC

  • Emergency Medicine Physician
  • Simpsonville, SC
  • NPI 1255170361
  Medicare reassignment
• Cep America LLC

  • Emergency Medicine Physician
  • Hilton Head Island, SC
  • NPI 1609689728
  NPD
• Cep America LLC

  • Emergency Medicine Physician
  • Fort Lauderdale, FL
  • NPI 1700747946
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1187222400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1746489600000",
    "number": "1427240019",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "32051 GROVE ST",
            "city": "AVON LAKE",
            "state": "OH",
            "postal_code": "440121906",
            "telephone_number": "440-930-2802"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "32051 GROVE ST",
            "city": "AVON LAKE",
            "state": "OH",
            "postal_code": "440121906",
            "telephone_number": "440-930-2802"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILLOUGHBY",
        "first_name": "KENNETH",
        "name_prefix": "Mr.",
        "name_suffix": "Jr.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-08-16",
        "last_updated": "2025-05-06",
        "certification_date": "2025-05-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "SC",
            "license": "4370",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Wyatt Demarco Massage Therapy & Wellness Center
• Jessica Rae Wyatt, LMT

• Physician Assistant in Avon Lake, OH
• Providers in Avon Lake, OH by specialty
• Physician Assistant in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.