Provider Demographics
NPI:1194870634
Name:BROWN, KEVIN NATHANIEL (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:NATHANIEL
Last Name:BROWN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1752
Mailing Address - Country:US
Mailing Address - Phone:952-442-2191
Mailing Address - Fax:952-442-7852
Practice Address - Street 1:560 S MAPLE ST STE 400
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1757
Practice Address - Country:US
Practice Address - Phone:952-442-8011
Practice Address - Fax:952-442-7852
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007007522084N0400X
MN163082084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00417871OtherRAILROAD MEDICARE
NC5907716Medicaid
NC2069467Medicare PIN