Provider Demographics
NPI:1639170723
Name:HITES, KEVIN MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:HITES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 E LAKE BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6771
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:
Practice Address - Street 1:15476 DEDEAUX RD STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2637
Practice Address - Country:US
Practice Address - Phone:228-230-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.255363A00000X, 207P00000X
ALPA225363AM0700X, 363AS0400X
MSPA00945363A00000X
FLPA9108726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51181661OtherBCBS AL
AL51181661OtherBCBS AL
AL102I973550Medicare PIN
AL51145264OtherBLUE CROSS BLUE SHIELD OF AL
AL1639170723OtherTRICARE SOUTH
AL511-01662OtherBCBS
AL511-01660OtherBCBS
AL511-01663OtherBCBS
ALP21791Medicare UPIN
AL051503556Medicare ID - Type Unspecified
AL116514Medicaid
AL116516Medicaid