Provider Demographics
NPI:1386696631
Name:KINGSLEY, KEVIN P (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:KINGSLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 N ORANGE AVE STE 411
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4644
Mailing Address - Country:US
Mailing Address - Phone:407-303-1373
Mailing Address - Fax:407-303-0852
Practice Address - Street 1:2501 N ORANGE AVE STE 411
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4644
Practice Address - Country:US
Practice Address - Phone:407-303-1373
Practice Address - Fax:407-303-0852
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3008363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290275300Medicaid
FLS67680Medicare UPIN
FL290275300Medicaid