Provider Demographics
NPI:1124047949
Name:LEWELLEN, KEVIN A (CRNA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:LEWELLEN
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:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0649
Mailing Address - Country:US
Mailing Address - Phone:928-729-8000
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF ROUTE N12 AND N7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11125367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3626474Medicaid
TN4024090OtherBLUE CROSS PROVIDER NUMBE
TN430066708OtherRR MEDICARE
TN3626474Medicare PIN