Provider Demographics
NPI:1124056502
Name:KON, KEVIN (PAC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27208 N 65TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085
Mailing Address - Country:US
Mailing Address - Phone:623-825-5022
Mailing Address - Fax:
Practice Address - Street 1:1066 N POWER RD
Practice Address - Street 2:STE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205
Practice Address - Country:US
Practice Address - Phone:480-776-1588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3082363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ043383Medicaid
AZ043383Medicaid