Provider Demographics
NPI:1063733574
Name:BOGART, KEVIN PATRICK (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:BOGART
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W 6TH AVE
Mailing Address - Street 2:FAMILY AND INTERNAL MEDICINE CLINIC - MC 3250
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-5182
Mailing Address - Country:US
Mailing Address - Phone:303-602-8070
Mailing Address - Fax:303-602-8176
Practice Address - Street 1:301 W 6TH AVE
Practice Address - Street 2:FAMILY AND INTERNAL MEDICINE CLINIC MC3250
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-5182
Practice Address - Country:US
Practice Address - Phone:303-602-8070
Practice Address - Fax:303-602-8176
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO3010363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91323533Medicaid