Provider Demographics
NPI:1447346499
Name:MALTAIS, KEVIN JAMES (CRNA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:MALTAIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:
Practice Address - Street 1:568 RUIN CREEK RD
Practice Address - Street 2:SUITE 105
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2880
Practice Address - Country:US
Practice Address - Phone:252-436-1380
Practice Address - Fax:252-436-1851
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167055367500000X
NC181612367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051607Medicaid
NC2603782Medicare ID - Type Unspecified
NC8051607Medicaid
NC2352680AMedicare PIN