Provider Demographics
NPI:1124796289
Name:KISSOON, KEVIN A (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:KISSOON
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 1:1377 DRESDEN DR NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3400
Mailing Address - Country:US
Mailing Address - Phone:407-620-2007
Mailing Address - Fax:
Practice Address - Street 1:1377 DRESDEN DR NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-3400
Practice Address - Country:US
Practice Address - Phone:407-620-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant