Provider Demographics
NPI:1740359314
Name:HALL, KEVIN (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HALL
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:PO BOX 2818
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85232-2818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:660 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85232
Practice Address - Country:US
Practice Address - Phone:949-713-3998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2493363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant