Provider Demographics
NPI:1124122858
Name:HUFFMAN, KEVIN PAUL (PAC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:PAUL
Last Name:HUFFMAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2505 MISSION DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-9508
Mailing Address - Country:US
Mailing Address - Phone:573-681-3759
Mailing Address - Fax:573-681-3659
Practice Address - Street 1:2505 MISSION DR
Practice Address - Street 2:SUITE 200
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-9508
Practice Address - Country:US
Practice Address - Phone:573-681-3759
Practice Address - Fax:573-681-3659
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03301363A00000X
MO2012042655363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO140940005Medicare PIN
TX8K6691Medicare PIN
TX8K6691Medicare Oscar/Certification