Provider Demographics
NPI:1104808674
Name:GEORGE, KEVIN BRUCE (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:BRUCE
Last Name:GEORGE
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 1:1917 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3585
Mailing Address - Country:US
Mailing Address - Phone:336-903-7845
Mailing Address - Fax:336-903-7841
Practice Address - Street 1:1917 W PARK DR
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3585
Practice Address - Country:US
Practice Address - Phone:336-903-7845
Practice Address - Fax:336-903-7841
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010847363AM0700X
PAMA052674363AS0400X
NC103761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA117326JT3Medicare UPIN